1. Study background
Complex social environment and changing life patterns in modern society are causing more emergency situations (disasters, acute disorders, intoxication, and accidents) that result in emergency patients. Therefore, there is an increasing interest in the general population regarding emergency medical care, as well as an increasing demand for emergency medical services. In addition, there is an increased demand for an improved quality of emergency medical care, with changing lifestyle and disease structure resulting in a remarkably increased number of emergency patients and a desire for improved quality of life accompanying economic development.
Lastly, with an increasing number of workers working five days per week, more people will spend extra time on leisure activities, and therefore the number of traumatic accidents is expected to increase. Therefore, the establishment of an emergency medical service system at the national and regional levels must be completed with efforts from both the national and regional governments.
In South Korea, the pre-hospital phase emergency medical response system was originally divided into the 119 ambulance service under the Korean National Fire Agency and the 1339 Emergency Medical Information Center under the Ministry of Health and Welfare. However, with the amendment of the Act on the 119 Rescue and Emergency Medical Services
by the National Assembly of the Republic of Korea in 2012, the 1339 Emergency Medical Information Center was closed. Instead, the 119 service has become a comprehensive center for medical emergencies (reporting an incident, dispatching the ambulance, hospital guidance, first aid guidance, and transferring the patient to an appropriate medical center) in attempt to provide a “one-stop” service for patients. In addition, 119 Emergency Control Centers have been established and operate at the Korea National Fire Agency and its headquarters in different cities and provinces.
The 119 Emergency Control Center, pursuant to Article 10 (2) of the Act on 119 Rescue and Emergency Medical Services, is responsible for the following: hospital guidance, consultation and instruction for emergency patients; instructing the first aid protocol for the emergency patients in transit; providing information on the medical center where the patient will be transported; utilizing and providing information related to emergency medical care; and establishing, managing, and operating the 119 emergency-transportation-related information network. Since the consolidation of the 119 and 1339 systems, Emergency Medical Dispatchers (EMD) have been providing instructions for Dispatcher Assisted Cardiopulmonary Resuscitation (DA-CPR) and first aid information for patients with cardiac arrest.
The most important aspect in treating a patient with cardiac arrest is the role of the witness, since the occurrence of cardiac arrest is often not predictable and the patient cannot report the incident or go to a medical center by him/herself. Moreover, cardiac arrest most frequently occurs in one’s house, public areas, or athletic centers—usually far away from medical centers. Thus, a witness of cardiac arrest with no medical expertise should be able to inform the emergency medical service system immediately and
perform CPR as soon as possible. Within 4-5 minutes of cardiac arrest, the brain starts to suffer damage. Therefore, immediate CPR by a witness is essential to minimize brain damage, even if the patient recovers from cardiac arrest (Hwang SO et al., 2011). In order to improve the survival rate of emergency patients (including cardiac arrest patients), a system called the
“Chain of Survival” is used. This concept, comprising early access, early Basic Life Support (BLS), early defibrillation, and early Advanced Cardiac Life Support (ACLS), needs all of its components working and flowing flawlessly to improve the chances of the patient’s survival (Lund et al., 2010).
Early access and BLS are often performed at the pre-hospital phase, and the importance of appropriate treatment at this stage cannot be overemphasized (Moon JD et al., 2005).
Fig. 1. chine of survival.
Cardiopulmonary Resuscitation (CPR) is a technique to resuscitate a human body that is undergoing the process of death after cardiac arrest, and it contributes to saving lives from death caused by temporary and reversible reasons. Since its initial development as a simple method of ancillary circulation and respiration for humans with ceased heartbeat and respiration, CPR has become a comprehensive medical technique as a response to cardiac arrest, with development of resuscitation medicine in the past couple centuries
(Hwang SO, 2012).
CPR performed by the initial witness at the accident site has effects on the survival and prognosis of the patient with cardiac arrest (Connolly et al., 2007), and a previous study by Hanche and Waage indicated that the survival rate with CPR performed by a witness was 18.8%. In Korea, there are different reports showing different numbers, but the survival rate ranges between 2.5 and 7%. More specifically, a study by Korea Centers for Disease Control and Prevention (KCDC) in 2008 showed that the survival rate of patients with cardiac arrest was 2.4%, which is remarkably low compared to the survival rates in developed countries (15–18%) where CPR is widely known. The rate of cardiac arrest witness performing CPR in Korea is merely 2–10%, while the rate in developed countries is 30–50%. This difference is likely the main reason for the low survival rate of patients with cardiac arrest (Hwang SO et al., 2011). The key reasons for low rate of CPR performance include inefficient training methods, lack of repeated training, lack of assessment after training, and the complex protocol of CPR (Cho JP et al., 2007).
Consolidation and separation of emergency telephone numbers may have different effects for reporters and service providers. From the reporter’s point of view, having fewer emergency telephone numbers makes it easier to remember them. However, for service providers, providing different types of services from a single telephone number may result in a reduced level of professionalism. Although several emergency telephone numbers have been consolidated so that only 112, 119, and 110 remain as of 2016, this only applies to the reporters and the traditional registration system, and telephone numbers from the service providers remained unchanged.
Developed countries (e.g., the United State and Japan) operate both
emergency telephone numbers (911 for the U.S. and 119 for Japan) and non-emergency numbers (311 for the U.S. and #7119 for Japan) so that the reporters can self-differentiate the level of emergency and use appropriate emergency centers. For less severe symptoms, the non-emergency number is used to obtain information regarding medical centers or medical consultation;
this allows for the prevention of unnecessarily overpopulated emergency rooms and wastage of emergency medical team resources (Richard et al., 2009; Morimura et al., 2011). Nevertheless, as of 2012 in Korea, the emergency telephone number was consolidated into 119—a comprehensive center for medical emergencies (reporting an incident, dispatching the ambulance, hospital guidance, first aid guidance, and transferring the patient to an appropriate medical center)—in an attempt to provide a “one-stop”
service for patients.
For cardiac arrest in emergency patients, it is difficult for general people to provide accurate and appropriate early response. Therefore, the Ministry of Health and Welfare, KCDC, and Korean Association of Cardiopulmonary Resuscitation (KACPR) recommend that the EMD should direct the witness over the phone to perform dispatcher-assisted CPR (DA-CPR) (Ministry of Health & Welfare, 2017). Although the rates are still low compared to those of developed countries, according to analyses of the statistics from 2006–2016 for acute cardiac arrest in Korea, the rate of CPR performed by witness has increased to 16.8% (2016), and the survival rate has increased to 7.6% (2016) (Kim YT, 2017). Since telephone-guided DA-CPR is one of the key methods to improve the rate of CPR performed by witness, comprehensive analysis and efficient future operation by 119 Emergency Control Centers are essential.
2. Study purpose
This study assessed pre-hospital phase emergency call usage before and after the consolidation of emergency telephone numbers, investigated the usage status by region and reasons for consultation after stabilization of the Emergency Rescue Standard System (ERSS) operated by the 119 Emergency Control Center, and analyzed the usage status of the 119 Emergency Control Centers for witness-performed CPR and first aid treatment with guidance from the newly introduced emergency medical dispatcher (EMD) after the consolidation of the telephone numbers, in order to provide an improvement plan for the system.
3. Definition of terms
(A) 119 Emergency Control Centers
119 Emergency Control Centers are established and operated at the Korea National Fire Agency and its headquarters at different cities and provinces. Based on Article 10 (2) of the Act on 119 Rescue and Emergency Medical Services, 119 Emergency Control Centers perform the following tasks:
provide guidance and consultation for emergency patients, provide information for transporters regarding the first aid treatment and destination (medical center); provide information regarding emergency medical care and its utilization; and establish, manage, and operate the 119 emergency transportation-related information network.
(B) Emergency Medical Dispatcher (EMD)
Emergency medical dispatchers working at 119 Emergency Control Centers are responsible for providing guidance and consultation in emergencies. They are health care providers, 1st and 2nd class emergency medical technicians (EMT), or experienced consultants with at least two
years of experience in providing consultation for emergency medical care at Emergency Medical Information Centers, based on the Act on 119 Rescue and Emergency Medical Services.
(C) Emergency Rescue Standard System (ERSS)
The Emergency Rescue Standard System (ERSS) is a firefighting and disaster management information system operated by the Korea National Fire Agency and its headquarters in different cities and provinces. The system provides comprehensive control of disastrous emergency events (fire, situations that require rescue activity, and emergency situations) from registration of the event to the 119 system and dispatch instructions to control of the situation.
B. Scope of the study & Materials and Methods
1. Scope of the study
In this study, 19,439 cases comprising 119 Emergency Control Center usage cases and CPR and first aid cases registered in the Emergency Rescue Standard System (ERSS) between January and December 2016 were used for the analysis.
2. Subjects of the study
This study has three main components. First, emergency call usage before and after the consolidation of emergency telephone numbers was assessed. Second, the usage status by region and reasons for consultation after stabilization of the Emergency Rescue Standard System (ERSS) operated by the 119 Emergency Control Center were analyzed. Third, the registered content of newly introduced cardiopulmonary resuscitation (CPR) and first aid protocols after the consolidation of emergency telephone numbers was
investigated.
(A) Assessment of the emergency call usage before and after the consolidation of emergency telephone numbers
Electronic record-based data of 1339 Emergency Medical Information Center from January–December 2011 prior to the consolidation of 119 and 1339 on June 2012, as well as the operational performance of the 119 Emergency Control Center in 2016, after the stabilization of ERSS, were analyzed. Prior to the consolidation, the statistical program for operational performance was on the same page as the consultation content report, broken down as follows: hospital guidance, disease consultation, guidance of emergency medical care, communication with ambulance dispatch, transfers between medical centers, and other. After consolidation, the following categories applied: hospital guidance, disease consultation, guidance of emergency medical care, guidance of medical care, transfers between medical centers, and other. Guidance of medical care prior to the consolidation was considered “disease consultation” or “guidance of emergency medical care,”
while communication with ambulance dispatch was categorized as “other.”
From the client’s perspective, data on the information center in the 2011 statistics and those on 129 were included as related organizations, while overseas residents and ships were categorized as other.
(B) Usage status of the 119 Emergency Control Center after consolidation of emergency telephone numbers
Prior to the consolidation, the 1339 Emergency Medical Information Center was operated by the Ministry of Health and Welfare, with 12 different regional offices at the following locations: Seoul (Seoul and Jeju regions), Busan (Busan and Ulsan regions), Incheon (Incheon region), Daegu (Daegu and Gyeongbuk regions), Daejeon (Daejeon and Chungcheong regions),
Gwangju (Gwangju and Jeonnam regions), Suwon (South Gyeonggi region), Uijeongbu (North Gyeonggi region), Jeonju (Jeonbuk region), Masan (Gyeongnam region), Wonju (West Gangwon region), and Gangneung (East Gangwon region). After the consolidation, pursuant to Article 10 (2) of the Act on 119 Rescue and Emergency Medical Services, the 119 Emergency Control Center and regional fire department headquarters worked together to enforce the Special Act on the Restructuring of Local Administrative Systems. Including the city of Changwon, one of the local governments in South Korea, 18 different fire department headquarters have been established and are being operated. The usage status of the 119 Emergency Control Centers in 2016 was analysed by region and reason for consultation, as well as the usage per 1,000 people.
(C) Usage status of CPR and first aid
Among 397,620 cases of emergency medical care guidance calls registered at the 119 Emergency Control Center between January and December 2016, retrospective analysis was performed on 19,439 CPR and first aid guidance call logs for emergency patients suspected of choking, no respiration, suffocation, foreign substance in airway, drowning, cardiac arrest from unclear external factor, or traumatic cardiac arrest from traffic accident or falling.
The date of the call is automatically given by the ERSS. Information regarding the age, gender, status of the patient, relationship between the patient and CPR provider (witness), and CPR provider’s status on previous CPR training were collected by the EMD via Q&A with the reporter (caller).
If no response was given or no information was collected, the case was excluded from the study. If the patient was under cardiac arrest or similar condition, the reporter was asked to perform CPR according to the standard
manual developed by the Korea National Fire Agency.
3. Statistical analysis
The operational performance of the Emergency Medical Information Centers in 2011 was combined with computerized data of the emergency medical information system. Statistical analyses of the data from the 119 Emergency Control Center in 2016 were performed using Excel. Among performance data of CPR and first aid guidance, correlations among the categories with CPR guidance were statistically analyzed. Data obtained from this analysis were encoded and entered into SPSS ver. 18.0 (SPSS Inc., Chicago, IL, USA). For statistical analysis of continuous and categorical variables, t-tests and chi-square tests were used, respectively. P < 0.05 was considered statistically significant.
Ⅱ Theoretical background of the emergency medical service system
A. The concept of an emergency medical service system
1. Significance of the emergency medical service system
In an emergency medical service system, an emergency patient is defined as a patient with severe, life-threatening injuries or conditions (disease, childbirth, accidents, or injuries from disasters) that require immediate medical care to avoid fatal outcomes. The entire process from the moment that patient is under a life-threatening condition until recovery (or elimination of life-threatening factors)—which involves consultation, rescue, transportation, and emergency/medical care—is defined as emergency medical care. Since emergency medical care directly affects the patient’s life under emergency situations, the system needs to be very detailed and cohesive.
The Emergency Medical Service System (EMSS) is a re-distribution of human workforce, facilities, and equipment for efficient operation of these resources under different circumstances (i.e., emergency situations occurring in areas of different sizes). Appropriate emergency care at the site, rapid and safe transportation of the patient, and proper treatment (medical equipment and staff) at medical institutions are all vital components of the system.
Therefore, in order to provide the best quality emergency medical service in the shortest period of time, the establishment of a co-operative system between the 119 emergency team, the 119 Emergency Control Center, and the medical center where the patient is being transported (and its emergency medical staff) is essential (Do BS et al., 2007).
The Korean legislation on emergency medical care states the rights of
citizens, including the rights to receive and be informed about emergency care, the obligation to report and assist with handling emergency patients, and exemption from responsibility for emergency care provided with good intentions. The rights and obligations of emergency medical care specialists include the following: the provision of treatment for patients who refuse emergency care or who are not emergency patients; prioritized emergency care for emergency patients; explanation and obtaining consent to receive emergency care; a prohibition on stopping emergency care; transportation of emergency patients; and a prohibition on hindering emergency care. The obligations of national and municipal governments include: the provision of emergency care; establishment and operation of emergency medical service system; operation of an emergency care committee; education on rescue and emergency care; establishment of an emergency care information network;
financial support; evaluation of emergency medical care centers; and measures to be taken in case of multiple patients.
2. Management of the emergency medical service system
The emergency medical service system, depending on the location of emergency care service provision, largely consists of the pre-hospital phase and the in-hospital phase. The pre-hospital phase includes the reporting of emergency patients (119 report), dispatching the medical emergency team to the site, and transporting the patient to the medical center. The in-hospital phase includes continuous emergency medical care provided for the transported patient, emergency surgeries, and transfer to specialized emergency medical centers.
(A) Pre-hospital phase
(1) Reporting of the emergency patient and dispatching of ambulance
(2) Providing dispatcher-instructed emergency care (first aid) until the ambulance reaches the site
(3) On-site emergency care provided by paramedics
(4) Determining the medical center for the patient to be transported to, via information sharing among the ambulance-emergency medical center-119 Emergency Control Center using an established information/communication network, and providing treatment on the way to the medical center
(B) In-hospital phase
(1) Examination of on-site treatment and provision of continuous emergency care
(2) Appropriate medical examinations to make diagnosis
(3) Determination of treatment method – hospitalization (general ward, ICU) or emergency surgery
(4) Determination of whether or not the patient requires transfer to a specialized emergency medical center (traumatic injury, burns, intoxication, or cardiovascular diseases) for optimal medical care, as well as the destination hospital (if the patient requires transfer)
B. Need for the emergency medical service system
1. Need for the emergency medical service system
The increased number of automobiles and other means of transport is one of the results of industrialization and development in the modern era, along with a consequent increase in the number of accidents. In addition, modernization has resulted in an increased number of accidents of various other kinds (accidents during operations at companies, gas or fire in highly
populated residential buildings). These accidents inevitably produce casualties, and most of these patients require emergency care as soon as possible.
Furthermore, the increased number of chronic degenerative diseases is another key factor that increases the demand for emergency care, as they result in cerebrovascular diseases (cerebral infarction) or ischemic heart diseases (Korea Institute of Health Services Management, 1996).
According to the National Statistics Office of Korea, the most frequent external cause of death is cancer, followed by cardiovascular diseases (52.5 deaths per 100,000 people in 2012). Cerebrovascular diseases are ranked third with 51.1 deaths per 100,000 people, and their incidence is increasing. The mortalities from traffic accidents, according to the 2011 National Competitiveness Report published by the Korean Ministry of Economy and Finance, was 2.9 per 10,000 automobiles—which was more than two-fold higher than the OECD average (1.3 people) or other countries such as the U.S. (1.4 people), France (1.2 people), or Australia (1.0 people), and more than three-fold higher than the U.K. (0.8 people), Germany (0.9 people), Japan (0.7 people), or Sweden (0.7 people). Despite its importance, there is a minimal level of interest in the emergency medical service system in Korea, unlike other developed countries or other medical specialties (Gwangju Metropolitan City, 2000).
In order for emergency patients to receive appropriate treatment at the right time, there are several things that need to be established (e.g., emergency care and specialist care at the site and in the ambulance, an emergency medical dispatch system that allows for rapid reporting of emergency accidents) to increase the public’s quality of life. In addition, in order to reduce the disability rate of emergency patients and improve survivability in trauma patients, an adequate emergency medical service
system that reflects the conditions in Korea needs to be developed.
system that reflects the conditions in Korea needs to be developed.