EMERGENCY MEDICINE, formerly known in some countries as ACCIDENT AND EMERGENCY MEDICINE, is the medical specialty involving care for undifferentiated and unscheduled patients with illnesses or injuries requiring immediate medical attention. In their role as first-line providers, emergency physicians are responsible for initiating investigations and interventions to diagnose and/or treat patients in the acute phase (including initial resuscitation and stabilization), coordinating care with physicians from other specialities, and making decisions regarding a patient's need for hospital admission, observation, or discharge. Emergency physicians generally practice in hospital emergency departments , pre-hospital settings via emergency medical services , and intensive care units , but may also work in primary care settings such as urgent care clinics.
Different models for emergency medicine exist internationally. In countries following the Anglo-American model, emergency medicine was originally the domain of surgeons , general practitioners , and other generalist physicians, but in recent decades it has become recognised as a speciality in its own right with its own training programmes and academic posts, and the specialty is now a popular choice among medical students and newly qualified medical practitioners. By contrast, in countries following the Franco-German model, the speciality does not exist and emergency medical care is instead provided directly by anesthesiologists (for initial resuscitation), surgeons, specialists in internal medicine , or another speciality as appropriate. In developing countries, emergency medicine is still evolving and international emergency medicine programs offer hope of improving basic emergency care where resources are limited.
* 1 Scope
* 1.1 Work patterns
* 2 History
* 3 Financing and practice organization
* 3.1 Reimbursement
* 3.1.1 Compensation * 3.1.2 Payment Systems * 3.1.3 Overutilization
* 3.2 Uncompensated care
* 3.2.1 EMTALA
* 3.3 Care Delivery in Different ED Settings
* 3.3.1 Rural * 3.3.2 Urban * 3.3.3 Patient-Provider Relationships * 3.3.4 Medical error
* 4 Treatments
* 5 Training
* 5.1 Argentina * 5.2 Australia and New Zealand * 5.3 Canada * 5.4 China * 5.5 Germany * 5.6 India * 5.7 Malaysia * 5.8 Saudi Arabia
* 5.9 United States
* 5.9.1 Funding for Training
* 5.10 United Kingdom * 5.11 Turkey * 5.12 Pakistan * 5.13 Iran
* 6 Ethical and medicolegal issues * 7 See also * 8 References * 9 Further reading * 10 External links
Main article: Outline of emergency medicine
The field of emergency medicine encompasses care involving the acute care of internal medical and surgical conditions. In many modern emergency departments, Emergency physicians are tasked with seeing a large number of patients, treating their illnesses and arranging for disposition—either admitting them to the hospital or releasing them after treatment as necessary. The emergency physician requires a broad field of knowledge and advanced procedural skills often including surgical procedures, trauma resuscitation, advanced cardiac life support and advanced airway management. They must have the skills of many specialists—the ability to resuscitate a patient (critical care medicine ), manage a difficult airway (anesthesia ), suture a complex laceration (plastic surgery ), reduce (set) a fractured bone or dislocated joint (orthopedic surgery ), treat a heart attack (cardiology ), manage strokes (neurology ), work-up a pregnant patient with vaginal bleeding (obstetrics and gynecology ), stop a severe nosebleed (ENT ), place a chest tube (cardiothoracic surgery ), and to conduct and interpret x-rays and ultrasounds (radiology ). Emergency physicians also provide episodic primary care to patients during off hours and for those who do not have primary care providers.
Physicians specializing in emergency medicine can enter fellowships to receive credentials in subspecialties such as palliative care, critical-care medicine , medical toxicology , wilderness medicine , pediatric emergency medicine , sports medicine , disaster medicine , tactical medicine, ultrasound, pain medicine, pre-hospital emergency medicine , or undersea and hyperbaric medicine .
The practice of emergency medicine is often quite different in rural areas where there are far fewer consultants and health care resources. In these areas, family physicians with additional skills in emergency medicine often staff emergency departments. Rural emergency physicians may be the only health care providers in the community, and require skills that include primary care and obstetrics.
Patterns vary by country and region. In the United States, the employment arrangement of emergency physician practices are either private (with a co-operative group of doctors staffing an emergency department under contract), institutional (physicians with an independent contractor relationship with the hospital), corporate (physicians with an independent contractor relationship with a third-party staffing company that services multiple emergency departments), or governmental (for example, when working within personal service military services, public health services, veterans' benefit systems or other government agencies).
In the United Kingdom, all consultants in emergency medicine work in the National Health Service and there is little scope for private emergency practice. In other countries like Australia, New Zealand or Turkey, emergency medicine specialists are almost always salaried employees of government health departments and work in public hospitals, with pockets of employment in private or non-government aeromedical rescue or transport services, as well as some private hospitals with emergency departments; they may be supplemented or backed by non-specialist medical officers, and visiting general practitioners . Rural emergency departments may be headed by general practitioners alone, sometimes with non-specialist qualifications in emergency medicine.
During this period, groups of physicians began to emerge who had left
their respective practices in order to devote their work completely to
the ED. In the UK in 1952, Maurice Ellis was appointed as the first
"casualty consultant " at
Leeds General Infirmary
It was not until the establishment of American College of Emergency
Physicians (ACEP), the recognition of emergency medicine training
programs by the AMA and the AOA , and in 1979 a historical vote by the
American Board of Medical Specialties that emergency medicine became a
recognized medical specialty in the US. The first emergency medicine
residency program in the world was begun in 1970 at the University of
Cincinnati and the first Department of Emergency
In 1990 the UK's Casualty Surgeons Association changed its name to
the British Association for Accident and Emergency Medicine, and
subsequently became the British Association for Emergency Medicine
(BAEM) in 2004. In 1993, an intercollegiate Faculty of Accident and
FINANCING AND PRACTICE ORGANIZATION
Many hospitals and care centers feature departments of emergency medicine, where patients can receive acute care without an appointment. While many patients are treated for life-threatening injuries, others utilize the emergency department (ED) for non-urgent reasons such as headaches or a cold. (defined as “visits for conditions for which a delay of several hours would not increase the likelihood of an adverse outcome”). As such, EDs can adjust staffing ratios and designate an area of the department for faster patient turnover to accommodate a variety of patient needs and volumes. Policies have been developed to better assist ED staff(such as Emergency Medical Technicians , paramedics , and mid level providers such as nurses and physicians assistants ) direct patients towards more appropriate medical settings, such as their primary care physician, urgent care clinics or detoxification facilities. The emergency department, along with welfare programs and healthcare clinics, serves as a critical part of the healthcare safety net for patients who are uninsured, cannot afford medical treatment or do not understand how to properly utilize their coverage.
Emergency physicians are compensated at a higher rate in comparison to some other specialities, ranking 10th out of 26 physician specialties in 2015, at an average salary of $306,000 annually. They are compensated in the mid-range (averaging $13,000 annually) for non-patient activities, such as speaking engagements or acting as an expert witness; they also saw a 12% increase in salary from 2014 – 2015 (which was not out of line with many other physician specialties that year). While emergency physicians work 8–12 hour shifts and do not tend to work on-call, the high level of stress and need for strong diagnostic and triage capabilities for the undifferentiated, acute patient contributes to arguments justifying higher salaries for these physicians. Emergency care must be available every hour of every day, and requires a doctor to be available on site 24/7, unlike an outpatient clinic or some other hospital departments that have more limited hours, and may only call a physician in when needed. The necessity to have a physician on staff along with all other diagnostic services available every hour of every day is thus a costly arrangement for hospitals.
American health payment systems are undergoing significant reform
efforts, which include compensating emergency physicians through
“Pay for Performance ” incentives and penalty measures under
commercial and public health programs, including Medicare and
Medicaid. This payment reform aims to improve quality of care and
control costs, despite the differing opinions on the existing evidence
to show that this payment approach is effective in emergency medicine.
Initially, these incentives were only targeted toward primary care
providers (PCPs), but some would argue emergency medicine is primary
care, as no one refers patients to the ED. In one such program, two
specific conditions listed were directly tied to patients frequently
seen by emergency medical providers: acute myocardial infarction and
There are some challenges with implementing these quality-based incentives in emergency medicine in that patients are often not given a definitive diagnosis in the ED, making it difficult to allocate payments through coding. Additionally, adjustments based on patient risk-level and multiple co-morbidities for complex patients further complicate attribution of positive or negative health outcomes, and it is difficult to assess whether much of the costs are a direct result of the emergent condition being treated in acute care settings. It is also difficult to quantify the savings due to preventive care during emergency treatment (i.e. workup, stabilizing treatments, coordination of care and discharge, rather than a hospital admission). Thus, ED providers tend to support a modified fee-for-service model over other payment systems.
Some patients without health insurance utilize EDs as their primary form of medical care. Because these patients do not utilize insurance or primary care, emergency medical providers often face problems of overutilization and financial loss, especially since many patients are unable to pay for their care (see below). ED overuse produces $38 billion in wasteful spending each year (i.e. care delivery and coordination failures, over-treatment, administrative complexity, pricing failures, and fraud), and unnecessarily drains departmental resources, reducing the quality of care across all patients. While overuse is not limited to the uninsured, the uninsured comprise a growing proportion of non-urgent ED visits – insurance coverage can help mitigate overutilization by improving access to alternative forms of care and lowering the need for emergency visits. A common misconception pegs frequent ED visitors as a major factor in wasteful spending. However, frequent ED users make up a small portion of those contributing to overutilization and are often insured.
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. Moreover, physician knowledge of prices for treatment and analyses, discussions on costs with their patients, as well as a changing culture away from defensive medicine can improve cost-effective use. A transition towards more value-based care in the ED is an avenue by which providers can contain costs.
Doctors that work in the EDs of hospitals receiving Medicare funding are subject to the provisions of EMTALA . EMTALA was enacted by the US Congress in 1986 to curtail “patient dumping,” a practice whereby patients were refused medical care for economic or other non-medical reasons. Since its enactment, ED visits have substantially increased, with one study showing a rise in visits of 26% (which is more than double the increase in population over the same period of time). While more individuals are receiving care, a lack of funding and ED overcrowding may be impacting quality. To comply with the provisions of EMTALA, hospitals, through their ED physicians, must provide a medical screening and stabilize the emergency medical conditions of anyone that presents themselves at a hospital ED with patient capacity. If these services are not provided, EMTALA holds both the hospital and the responsible ED physician liable for civil penalties of up to $50,000 each. While both the Office of Inspector General, U.S. Department of Health and Human Services (OIG) and private citizens can bring an action under EMTALA, courts have uniformly held that ED physicians can only be held liable if the case is prosecuted by OIG (whereas hospitals are subject to penalties regardless of who brings the suit). Additionally, the Center for Medicare and Medicaid Services (CMS) can discontinue provider status under Medicare for physicians that do not comply with EMTALA. Liability also extends to on-call physicians that fail to respond to an ED request to come to the hospital to provide service. While the goals of EMTALA are laudable, commentators have noted that it appears to have created a substantial unfunded burden on the resources of hospitals and emergency physicians. As a result of financial difficulty, between the period of 1991–2011, 12.6% of EDs in the US closed.
CARE DELIVERY IN DIFFERENT ED SETTINGS
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”. While this still exists today to an extent as mentioned above, it is critical to consider the location in which care is delivered to understand the population and system challenges related to overutilization and high cost. 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. Unfortunately as a result, the incidence of complex co-morbidities not managed by the appropriate provider results in worse health outcomes and eventually costlier care that extends beyond rural communities. 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. (See: Rural health .)
Alternatively, emergency medicine in urban areas consists of diverse provider groups including PCPs, nurse practitioners, physicians, and registered nurses who coordinate with specialists in both inpatient and outpatient facilities to address patients’ needs, more specifically in the ED. 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. Fortunately, non-profit hospitals and health systems – as required by the ACA – must provide a certain threshold of charity care “by actively ensuring that those who qualify for financial assistance get it, by charging reasonable rates to uninsured patients and by avoiding extraordinary collection practices”. While there are limitations, this mandate provides support to many in need. 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. Upon making contact with a patient, EMS providers have a responsibility to diagnose and stabilize a patient’s condition without regard for ability to pay. 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, 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. This legal responsibility can extend to physician consultations and on-call physicians even without direct patient contact. 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. Hospitals and physicians must also ensure that the patient’s condition will not be further aggravated by the transfer process.
The unique setting of emergency medicine practice presents a
challenge for delivering high quality, patient-centered care. Clear,
effective communication can be particularly difficult due to noise,
frequent interruptions, and high patient turnover. The Society for
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. One study identified an error rate of 18 per 100 registered patients in one particular academic ED. Another study found that where a lack of teamwork (i.e. poor communication, lack of team structure, lack of cross-monitoring) was implicated in a particular incident of ED medical error, “an average of 8.8 teamwork failures occurred per case more than half of the deaths and permanent disabilities that occurred were judged avoidable.” Unfortunately, certain cultural (i.e. “a focus on the errors of others and a ‘blame-and-shame’ culture”) and structural (i.e. lack of standardization and equipment incompatibilities) aspects of emergency medicine often result in a lack of disclosure of medical error and near misses to patients and other caregivers. While concerns about malpractice liability is one reason why disclosure of medical errors is not made, some have noted that disclosing the error and providing an apology can mitigate malpractice risk. Ethicists uniformly agree that the disclosure of a medical error that causes harm is the duty of a care provider. The key components of disclosure include “honesty, explanation, empathy, apology, and the chance to lessen the chance of future errors” (represented by the mnemonic HEEAL). The nature of emergency medicine is such that error will likely always be a substantial risk of emergency care. Maintaining public trust through open communication regarding harmful error, however, can help patients and physicians constructively address problems when they occur.
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.
A brief review of some of these programs follows:
In Argentina, the SAE (Sociedad Argentina de Emergencias) is the main organization of Emergency Medicine. 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.
AUSTRALIA AND NEW ZEALAND
The specialist medical college responsible for Emergency
Dual fellowship programs also exist for Paediatric
For medical doctors not (and not wishing to be) specialists in
The two routes to emergency medicine certification can be summarized as follows:
* A 5-year residency leading to the designation of FRCP(EM) through
Royal College of Physicians and Surgeons of Canada (Emergency
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
The current post-graduate Emergency
About a decade ago, Emergency
In Germany, emergency medicine is not handled as a specialisation (Facharztrichtung), but any licensed physician can acquire an additional qualification in emergency medicine through an 80-hour course monitored by the respective "Ärztekammer" (medical association, responsible for licensing of physicians). A service as emergency physician in an ambulance service is part of the specialisation training of anaesthesiology . 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. Many private hospitals and institutes
have been providing Emergency
There are three universities (Universiti Sains Malaysia, Universiti
Kebangsaan Malaysia, payments are given to hospitals for each
resident. "Fifty-five percent of ED payments come from Medicare,
fifteen percent from Medicaid, five percent from private payment and
twenty-five percent from commercially insured patients." However,
choices of physician specialties are not mandated by any agency or
program, so even though emergency departments see many
Medicare/Medicaid patients, and thus receive a lot of funding for
training from these programs, there is still concern over a shortage
of specialty-trained Emergency
In the United Kingdom, the Royal College of Emergency
Historically, emergency specialists were drawn from anaesthesia, medicine, and surgery. Many established EM consultants were surgically trained; some hold the Fellowship of Royal College of Surgeons of Edinburgh in Accident and Emergency — FRCSEd(A -webkit-column-width: 30em; column-width: 30em; list-style-type: decimal;">
* ^ A B Sakr, M (2000). "Casualty, accident and emergency, or
emergency medicine, the evolution" . Emergency
* Marx, John (2010). Rosen's Emergency Medicine: concepts and
clinical practice (7th ed.). Philadelphia, PA: Mosby/Elsevier. ISBN
* Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive
Study Guide (Emergency
* International Federation for Emergency Medicine * Association of Emergency Physicians * Canadian Association of Emergency Physicians * American Academy of