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Opinions of Monday, 18 June 2018

Columnist: Dr. Maxwell Osei-Ampofo

One emergency patient, one emergency bed; Is it really about a bed?

A few questions will help us appreciate the situation better. Will an additional 50 or 100 Emergency Department (ED) beds donated to Korle Bu or Komfo Anokye or say 37 by a benevolent citizen who is not a spectator solve the “no bed syndrome”?

The institutions may replace their old Emergency beds with these new ones. But they will certainly not add to their capacity. Which Emergency Department or Emergency Room(ER) will they put these beds?

It is not as if there are Emergency care spaces without Emergency beds that need beds to fill. The absence of an Emergency bed at numerous health facilities leading to the loss of

Life of a human being as discussed on many platforms is just a symptom of a deeper Emergency care crisis.

The malady rather than the symptom is what we should focus our minds on and channel our energies and resources towards.

• What is an Emergency?

• Who determines what an Emergency is? (the patient or the security man or the health assistant or nurse or doctor or who?)

• Where can an Emergency occur (home, office, roadside, inside my car, workplace …. anywhere!!!)

• How can one get help in an emergency?

• How can one be moved from the place of the emergency to a definitive care facility?

• What communication system exists between the prehospital emergency care service and the definitive care facilities?

• What communication system exists between health care facilities?

• Should emergency care be paid for at the point of the service?

• Is the population well informed about their roles and responsibilities in the event of a medical emergency?

These questions if addressed sufficiently will form the framework for a functional and integrated Emergency Care system.

While a technical definition exists for what an emergency is; any life or limb threatening or potentially life or limb threatening illness or injury; the person who has a headache and wants to see a doctor may not know whether the headache is benign or malignant.

Therefore any person who feels he is experiencing life-threatening or potentially life threatening symptom (eg sudden chest pain, sudden weakness or numbness, bleeding etc) should receive a clinical evaluation by a qualified doctor.

Through a universal number (such as 193 for an ambulance, 192 for fire, 191 for police or 112 for all emergencies), the person or the relative or friend or co-worker as the case may be, should be able to get emergency prehospital care to where the ill or injured person is.

While a private vehicle or taxi can get such a person to the hospital, it is not advisable to do so since certain disease processes need specific time-bound prehospital interventions to optimise the outcome of such patients.

Taxis and private vehicles do not have trained Emergency Medical Technicians(EMTs) to perform such lifesaving interventions enroute to definitive care facilities.

Injuries, obstetric and gynaelogical bleeding, heart attack (myocardial infarction), stroke, sepsis and cardiac arrest are some of the emergency disease processes that are time sensitive and can only have good outcomes with a functional and well-structured prehospital emergency medical service.

Failure to respond timeously to such disease processes by the prehospital emergency service will mean a poor outcome for the ill or injured. Patients or relatives or friends not calling for help or ambulance not coming even after being called or a delay in coming due to limited number of ambulances are all contributory factors.

If and when an ambulance shows up, the prehospital personnel(EMTs) perform a field triage (sorting out) of this ill or injured person to determine his/her injury or illness severity(acuity).

This field triaging should then determine where the patient should be taken to.It should not be the case that all patients picked by an ambulance are sent to Korle Bu or 37 or Komfo Anokye just based on the “feeling” of the EMT.It should be based on this reproducible scientific method of field triaging.

But before the Prehospital service such as the National Ambulance Service(NAS) can do this, the Ministry of Health(MOH) and its other agencies such as the Ghana Health Service(GHS), CHAG, Teaching Hospitals etc should provide NAS with the list of all health facilities and the services available at those facilities based on the personnel and equipment.

The MOH again should categorise health facilities into Tiers based on the services that are consistently available. Re-imbursement by the National Health Insurance Authority(NHIA) should be based on this categorisation. Facilities that fall short of their service provision for that category should be reviewed downwards and their re-imbursement so affected.

If KATH or Korle Bu or 37 consistently for example fail to provide CT scan or MRI services, their re-imbursement for that period should be lower than a tertiary institution.

District and Regional hospitals that fall short of requirements for their category should suffer similar penalties. Managers will respond appropriately when they are losing money.

Primary prehospital transfers as well as interfacility transfers (one health facility to another) both require an effective communication network that allows for access to the number of emergency beds available in each facility as well as the levels of severity of injuries and illnesses that can be seen in those facilities.

The absence of such a communication system means that patients will be sent to mostly the likes of KATH and Korle Bu. The available emergency care space at these facilities are woefully inadequate compared to the populations they serve.

Low acuity (Lower severity) emergency cases should be attended to at the lower tiered health facilities to allow for emergency care space for high acuity (high severity) illnesses and injuries at the tertiary institutions.

A lot of patients show up to the emergency department with complications of a chronic illness such as hypertension or diabetes for which they were completely oblivious about.

Decreasing crowding or congestion at the ED also means decreasing the numbers of Emergency presentations through early screening, detection and treatment mechanisms by Family or General Physicians.

Funding for emergency care should be revisited. What aspects of emergency care are covered by the National Health Insurance? Many patients are occupying beds at the ED because of their inability to pay for a radiological investigation (CT scans and x-rays mostly) which will determine their disposition.

These emergency beds could have been freed for incoming emergencies if their investigations were paid for promptly.

Poor bed management within health facilities also contribute to poor patient flow leading to crowding/congestion at the ED thus preventing admission of new emergency patients.

There is an urgent need to increase the numbers of Functional Emergency Departments across the country. This requires an increase in the numbers of trained emergency physicians, emergency nurses and critical personnel; equipping these EDs with basic emergency care equipment such as ECGs, suction machines, airway devices, emergency medications and other resuscitation equipment and diagnostics.

Until there is an integrated emergency care system with enough and equipped ambulances staffed by well-trained EMTs, functional emergency departments with trained emergency physicians, emergency nurses and critical care personnel bridged by an effective communication network, lives may unfortunately be lost needlessly.