From Fragmentation to Integration in Emergency Medicine: Providing Care Our Patients Deserve
Main Article Content
Abstract
The emergency care systems of most communities around the world have multiple components through which patients move and which are, at best, disjointed and not well coordinated. Illnesses and injuries which begin in the community and frequently preventable often do not have the benefit of bystander assistance or dedicated immediate emergency ambulance care and arrive at Emergency Departments that are crowded. Patients often spend long hours in these Emergency Departments and, if requiring inpatient care, have to wait many hours before an inpatient bed becomes available. Those requiring further convalescent care may often find inadequate arrangements available for them to recover smoothly. The end result is delays and adverse clinical outcomes that are often not measured or even appreciated.
This report discusses each of ten components of the emergency care system as in exists in most communities, including injury and illness prevention, the community burden of emergencies, bystander first responder care, ambulance-based second responder care, emergency department crowding and its contributory factors, transitions of care to the inpatient departments and community convalescent care units, coordination of emergency departments in the community, the patient’s family and, of course, the emergency patient. The effects of fragmentation in each of these components are described and strategies to address each mentioned.
There is a need for a patient-centric, integrated approach to the provision of emergency care in any community which can break down the barriers created by fragmented care and provide the seamless, high-quality care that all our patients deserve.
Article Details
How to Cite
VENKATARAMAN, Anantharaman et al.
From Fragmentation to Integration in Emergency Medicine: Providing Care Our Patients Deserve.
Medical Research Archives, [S.l.], v. 12, n. 4, apr. 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/5279>. Date accessed: 27 july 2024.
doi: https://doi.org/10.18103/mra.v12i4.5279.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
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4. Prior, A., Vestergaard, C.H., Vedsted, P. et al. Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study. BMC Med. 2023; 21: 305. https://doi.org/10.1186/s12916-023-03021-3
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7. Kern, L. M.. Whether Fragmented Care Is Hazardous Depends on How Many Chronic Conditions a Patient Has. Fragmented Care Chronic Conditions Overuse Hospital Services | Commonwealth Fund. 2018; Retrieved September 19, 2022, from https://www.commonwealthfund.org/publications/journal-article/2018/oct/fragmented-care-chronic-conditions-overuse-hospital
8. Joo JY. Fragmented care and chronic illness patient outcomes: A systematic review. Nurs Open. 2023 Jun;10(6):3460-3473. Doi: 10.1002/nop2.1607. Epub 2023 Jan 9. PMID: 36622952; PMCID: PMC10170908.
9. Timmins L, Kern L, O’Malley A, Urato C, Ghosh A, Rich E. Communication Gaps Persist Between Primary Care and Specialist Physicians. Annals of Family Medicine. 2022; 20(4), 343–347. Doi:10.1370/afm.2781
10. Kailasam M, Guo W, Hsann YM, et al. Prevalence of care fragmentation among outpatients attending specialist clinics in a regional hospital in Singapore: a cross-sectional study. BMJ Open. 2019;9:e022965. Doi:10.1136/bmjopen-2018-022965
11. Kaltenborn Z, Paul K, Kirsch J. et al. Super fragmented: a nationally representative cross-sectional study exploring the fragmentation of inpatient care among super-utilizers. BMC Health Serv Res. 2021; 21: 338. https://doi.org/10.1186/s12913-021-06323-5
12. Liu CW, Einstadter D, Cebul RD. Care fragmentation and emergency department use among complex patients with diabetes. Am J Manag Care. 2010 Jun;16(6):413-20. PMID: 20560685.
13. Reynolds TA, Sawe H, Rubiano AM, et al. Strengthening Health Systems to Provide Emergency Care. In: Jamison DT, Gelband H, Horton S, et al., editors. Disease Control Priorities: Improving Health and Reducing Poverty. 3rd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank. 2017 Nov 27. Chapter 13. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525279/ Doi: 10.1596/978-1-4648-0527-1_ch13. Last accessed 11 March 2024.
14. Ehrenkranz PD, Ahn CJ, Metlay JP, Camargo CA Jr, Holmes WC, Rothman R. Availability of rapid human immunodeficiency virus testing in academic emergency departments. Acad Emerg Med. 2008; 15: 144–50.
15. Al-Tayyib AA, Miller WC, Rogers SM, et al. Evaluation of risk score algorithms for detection of chlamydial and gonococcal infections in an emergency department setting. Acad Emerg Med. 2008; 15: 126–35.
16. Pollock DA, Lowery DW, O’Brien PM. Emergency medicine and public health: new steps in old directions. Ann Emerg Med. 2001; 38: 675–83.
17. Clery M, Khaldun J. Emergency Physicians as Community Health Advocates. Annals of Emergency Medicine. 2019; 74(5): S62-S65.
18. Razzak J, Usmani MF, Bhutta ZA. Global, regional and national burden of emergency medical diseases using specific emergency disease indicators: analysis of the 2015 Global Burden of Disease Study. BMJ Global Health. 2019;4:e000733.
19. Anantharaman V, Lateef F. Acute Medicine in the Pre-hospital environment. A Clinical Approach to Medicine. Chapter 14, Editors Ong YY, Woo KT, Ng HS, Tan P, Tang OT, World Scientific, 2nd Edition. 2005; 239 – 259
20. Salhi RA, Macias-Konstantopoulos WL, Ryus CR. From the Editors - Future Directions to strengthen the Emergency Department Safety Net. West J Emerg Med. 2023 Sep;24(5):919-920. Doi: 10.5811/westjem.60719. PMID: 37788032; PMCID: PMC10527835.
21. Fischer P, Krueger JI, Greitemeyer T, et al. The bystander-effect: a meta-analytic review on bystander intervention in dangerous and non-dangerous emergencies. Psychol Bull. 2011; 137(4):517–537. [PubMed: 21534650]
22. Bednarz K, Goniewicz K, Al-Wathinani AM, Goniewicz M. Emergency Medicine Perspectives: The Importance of Bystanders and Their Impact on On-Site Resuscitation Measures and Immediate Outcomes of Out-of-Hospital Cardiac Arrest. J Clin Med. 2023 Oct 28;12(21):6815. Doi: 10.3390/jcm12216815. PMID: 37959280; PMCID: PMC10650602.
23. Faul M, Aikman SN, Sasser SM. Bystander Intervention Prior to The Arrival of Emergency Medical Services: Comparing Assistance across Types of Medical Emergencies. Prehosp Emerg Care. 2016 ; 20(3): 317–323. Doi:10.3109/10903127.2015.1088605
24. Kua PHJ, Ng KC, Anantharaman V. A pilot survey on bystander first aid for childhood injuries. Asian EMS Journal. 2015; 1. (1): 16-20.
25. Bakke HK, Steinvik T, Eidissen SI, Gilbert M, Wisborg T. Bystander first aid in trauma - prevalence and quality: a prospective observational study. Acta Anaesthesiol Scand. 2015 Oct;59(9):1187-93. Doi: 10.1111/aas.12561. Epub 2015 Jun 19. PMID: 26088860; PMCID: PMC4744764.
26. Al Khathaami AM, Mohammad YO, Alibrahim FS, Jradi HA. Factors associated with late arrival of acute stroke patients to emergency department in Saudi Arabia. SAGE Open Medicine. 2018;6.
27. Frisch SO, Faramand Z, Li H, Abu-Jaradeh O, Martin-Gill C, Callaway C, Al-Zaiti S. Prevalence and Predictors of Delay in Seeking Emergency Care in Patients Who Call 9-1-1 for Chest Pain. J Emerg Med. 2019 Nov;57(5):603-610. Doi: 10.1016/j.jemermed.2019.07.012. Epub 2019 Oct 12. PMID: 31615705; PMCID: PMC7104914.
28. Beltrán Guzmán I, Gil Cuesta J, Trelles M, Jaweed O, Cherestal S, van Loenhout JAF, et al. Delays in arrival and treatment in emergency departments: Women, children and non-trauma consultations the most at risk in humanitarian settings. PLoS ONE. 2019;14(3): e0213362. https://doi.org/10.1371/journal.pone.0213362
29. Ravindra P, Bhat R, Karanth N, Wilson W, Lavanya BN, Umra S, Mahesh S. Patterns and Predictors of Emergency Medical Services Utilisation by Patients Attending the Emergency Medicine Department of a Tertiary Care Hospital in India. J Emerg Trauma Shock. 2022 Apr-Jun;15(2):99-104. Doi: 10.4103/jets.jets_83_21. Epub 2022 Jun 27. PMID: 35910313; PMCID: PMC9336641.
30. Kironji, A., Hodkinson, P., de Ramirez, S.S. et al. Identifying barriers for out of hospital emergency care in low and low-middle income countries: a systematic review. BMC Health Serv Res. 2018; 18: 291 . https://doi.org/10.1186/s12913-018-3091-0
31. Williams DM. The Myth of the Perfect Model. EMS World. Global learning Network. 2006. https://www.hmpgloballearningnetwork.com/site/emsworld/article/10322477/myth-perfect-model. Last accessed 8 March 2024
32. Bhattarai HK, Bhusal S, Barone-Adesi F, Hubloue I. Prehospital Emergency Care in Low- and Middle-Income Countries: A Systematic Review. Prehosp Disaster Med. 2023 Aug;38(4):495-512. Doi: 10.1017/S1049023X23006088. Epub 2023 Jul 26. PMID: 37492946; PMCID: PMC10445116.
33. Ebben RH, Vloet LC, Verhofstad MH, Meijer S, Mintjes-de Groot JA, van Achterberg T. Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review. Scand J Trauma Resusc Emerg Med. 2013 Feb 19;21:9. Doi: 10.1186/1757-7241-21-9. PMID: 23422062; PMCID: PMC3599067.
34. MacKichan F, Brangan E, Wye L, Checkland K, Lasserson D, Huntley A, Morris R, Tammes P, alisbury C, Purdy S. Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice. BMJ Open. 2017 May 4;7(4):e013816. Doi: 10.1136/bmjopen-2016-013816. PMID: 28473509; PMCID: MC5623418.
35. McFadzean IJ, Edwards M, Davies F. et al. Realist analysis of whether emergency departments with primary care services generate ‘provider-induced demand’. BMC Emerg Med. 2022;22: 155 . https://doi.org/10.1186/s12873-022-00709-2
36. Ong EHM, Ornato JP, Cosby C, Franck T. Should the Emergency Department be society's health safety net? J Public Health Policy. 2005 Sep;26(3):269-81. Doi: 0.1057/palgrave.jphp.3200028. PMID: 16167554.
37. Pines JM, Bernstein SL. Solving the worldwide emergency department crowding problem – what can we learn from an Israeli ED? Isr J Health Policy Res. 2015; 4: 52 . https://doi.org/10.1186/s13584-015-0049-0
38. Anantharaman V, Seth P. Emergency department overcrowding. In: Kayden S, Anderson PD, Freitas R, Platz E, eds. Emergency Department Leadership and Management: Best Principles and Practice. Cambridge University Press. 2014;257-269.
39. Anantharaman V. Impact of health care system interventions on emergency department utilization and overcrowding in Singapore. Int J Emerg Med. 2008 Apr;1(1):11-20. Doi: 10.1007/s12245-008-0004-8. Epub 2008 Mar 14. PMID: 19384496; PMCID: PMC2536176.
40. Shen YC, Hsia RY. Association between ambulance diversion and survival among patients with acute myocardial infarction. JAMA. 2011 Jun 15;305(23):2440-7. Doi: 0.1001/jama.2011.811. Epub 2011 Jun 12. PMID: 21666277; PMCID: PMC4109302.
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