Status of Emergency Medicine Around the World - Hong Kong

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Status of Emergency Medicine Around the World-
Hong Kong
TRACK E

• Dr. LAU Chor-chiu
• Consultant and Chief-of-Service
• Pamela Youde Nethersole Eastern Hospital
• Hong Kong

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Hong Kong (Special Administrative Region)

• Population 6.787 million
• Area 1,102 square Km

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Hong Kong (Special Administrative Region)

• Location
• Southern part of Guangdong Province
• History
• British Colony from 1842, returned back to China
  on 1 Jul 1997

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Hong Kong (Special Administrative Region)

• International city predominantly Chinese descent
  (95), Cantonese speaking

• 2001 Census
• Population 6.7M
• Sex ratio (M/F)
• 0.956 1
• Age 0-14 16
• Age 15-64 72
• Age gt 65 11
• (Census and Statistics Department, HK)

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Hong Kong Population Age Pyramid
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Hong Kong (Special Administrative Region)

• Socio-economics
• Estimated GDP (2002) Eu146,101m
• Estimated total public spending on health care
  (2001/02) about 2.7 GDP

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Age specific Mortality Rates by Disease Groups
2001 (All age)
Neoplasm 172.8
Diseases of circulatory system 125.6
Disease of respiratory system 82.3
External causes of morbidity and mortality 27.4
Diseases of genitourinary system 21.5
Disease of digestive system 19.3
Certain infections and parasitic diseases 13.8
Endocrine, nutritional and metabolic diseases 11.5
Diseases of nervous system 4.6
Signs, symptoms abnormal clinical and laboratory findings, not classified elsewhere 4.5
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Health Care SYstem

• Public
• Hospital Authority manage all all public
  hospitals, major health institutes and general
  out patient clinics since 1 Jul 2003
• Government funding and responsible for 95 of
  medical service
• Recent financial reforms
• AE charging started since Nov 2003 (approx.
  Eu11.5 per attendance, including all
  investigations and prescription)
• In-patient care Eu9.2 daily, including all
  investigations, medication, operation and meals
• Private
• 5

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Medical Education

• 2 Universities, basically British system
• Chinese University of Hong Kong
• University of Hong Kong
• 5-year undergraduate study
• 1-year internship of four 3-month rotations

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EM specialty status

• 1st Casualty Unit established in Queen Mary
  Hospital in 1947
• Early years, staffed by junior doctors, fresh
  graduates while waiting for training in other
  branch of medicine
• One senior medical officer in-charge

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Birth of the Specialty

• Formation of the Hong Kong Society of Emergency
  Medicine in 1985
• Mini-journal (Emergi-News) in 1990 and maturation
  into Hong Kong Journal of Emergency Medicine in
  1994
• Establishment of Accident and Emergency Training
  Centre in Tang Shiu Kin Hospital in 1994

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Birth of the Specialty

• Incorporation of the Hong Kong College of
  Emergency Medicine (HKCEM) in 1996 and admitted
  as a constituent college of Hong Kong Academy of
  Medicine (HKAM) in 1997
• (HKAM was inaugurated in 1993, marked a new era
  in specialist training in Hong Kong)

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Hong Kong College of Emergency Medicine

• Specialist training programme of 6 years
  including
• Clinical experience
• Emergency medicine
• Internal Medicine and subspecialty
• General Surgery and subspecialty
• Other specialties

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Hong Kong College of Emergency Medicine

• Specialist training programme of 6 years
  including
• Other training requirement (Logbook)
• Cluster tutorial
• Case report / best evidence topics
• Joint Clinical Meeting / Toxicology Round /
  Scientific Meeting
• Clinical Skills Workshops

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Hong Kong College of Emergency Medicine

• 1st conjoint (intermediate) fellowship/membership
  examination with Edinburgh College in 1997
• 1st local exit examination in 1999 (with invited
  overseas examiners)
• Nominated for college fellowship after exit
  examination and fulfillment of training
  requirement

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EM specialty status

• 2003 14 training centres with full time staff
• Changing staffing composition
• Consultant(s) and Chief-of-Service with Senior
  Medical Officers (SMO) and Medical Officers (MO)
• Specialists (Consultants, SMO, MO)

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Academic Units

• Honorary teaching staff appointed by 2
  Universities since 1991, but no independent
  department
• 1995, Professor appointed in Emergency Medicine
  Academic Unit, Chinese University of Hong Kong

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Pre-hospital Care

• Government run Ambulance Service under Fire
  Service Department
• Free service
• Dispatch by Central control, staffed by senior
  fire officers
• Changing from simple first aid providers to
  Emergency Medical Technicians (EMA) with
  different levels since early 1990s

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Pre-hospital Care

• Special skills of EMA II
• IV lines and simple drugs by protocols
• Salbutamol nebulisation (puff) for asthma and
  COPD
• IVI Dextrose for hypoglycaemia
• IMI Naloxone for narcotic overdose
• Target for one EMA II on board of each ambulance
  in 2004

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Pre-hospital Care

• Advanced EMA II (with advanced airway management
  with special adjuncts, Combitube, Laryngeal Mask
  Airway)
• Not up to Paramedic level (no endotracheal
  intubation, No ACLS)

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Pre-hospital Care

• 1st (part-time) Medical Director appointed in
  1999
• Currently 2 part-time Medical Directors
• Moving towards EMA II and paramedic level
• To implement Trauma Diversion in Nov 03
• Consider different levels dispatch in future

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Current EM specialty status

• 14 training centres
• 120 specialists, 200 trainees
• 2 part-time Medical Director (Ambulance Service)

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EM System

• In-hospital emergency care
• Front door (gate) of hospital service
• Self referral by patients
• Secondary and tertiary referrals
• No closure even if no beds in hospital
• Multi-specialty model with no differentiation
  among AED staff
• Full admission right, except one (teaching
  hospital)
• Follow up Clinic
• Recent enhancement in Observation Medicine

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EM System

• In-hospital emergency care
• Various degree of cooperation with other
  specialties with agreed guidelines (Trauma team,
  ICU care)
• Urgent consultation available to subspecialties
  on call team or to specialist clinics

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Challenges and Strategies

• Heavy patient load
• Total attendance 2.5M in 2001/2
• PYNEH 10 specialists with 19 trainees to attend
  500 daily attendance
• Slight decrease with AE charging
• Major decrease after SARS in Mar-Apr 2003

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Challenges and Strategies

• Limited training opportunities
• Resources - Manpower issue
• Separate budget for each department
• No replacement for elective training,
  supernumerary staff for elective training in
  physician training
• Limited access to other non-major but essential
  specialties (Paed, OT, ICU, OG) gtgtgtgtgt delay in
  maturation of EM training

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Challenges and Strategies

• How are you trying to overcome these challenges?
• Friends with other chief of service
• Take chance of mutual need
• Recent support from Hospital Authority
  administrative means to decrease hospital
  admission gtgtgtgt Observation Medicine and access to
  supportive service

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Summary

• Emergency Medicine specialty in Hong Kong at
  paediatric stage development
• Difficulties from heavy workload, limited
  resources for training and cooperation from other
  specialties
• Getting more support from administration because
  of efficient gate keeper role to decrease
  hospital admission