China

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General

Capital – Beijing

Land Size – 9,596,901 sq km

Population – 1,330,141,295

Language(s) – Standard Chinese or Mandarin (Putonghua, based on the Beijing dialect), Yue (Cantonese), Wu (Shanghainese), Minbei (Fuzhou), Minnan (Hokkien-Taiwanese), Xiang, Gan, Hakka dialects, minority languages


Prehospital Care


Overview

  • “Since the early 1980s, many improvements in emergency care have been made in China. However, the connection between out-of-hospital and hospital care has not consistently materialized, leaving out-of-hospital EMS in early development” (Thomas, 151)
    • Most larger urban centers have begun EMS systems
    • Most rural areas have no EMS
      • Chinese EMS traditionally serves as extension of tertiary health care systems, which is less prominent in urban areas
  • “Chinese EMS principles have been ‘imported’ from differing foreign systems by Chinese professionals studying abroad” (Thomas, 151)
  • Beijing EMS – planned with input from Italian EMS
  • Shanghai EMS – more influence taken from US EMS


History

  • 1980s – Development of EMS in China begins (Thomas, 151)
    • MOPH issues “Directives to Further Strengthen the Emergency Care in Urban Areas” stressing pre-hospital emergency care
    • EMS planning
      • Hierarchical administrative system
        • Ministry of Public Health
        • Provincial bureaus (23 total)
        • Regional
        • City bureaus


EMS System Model

  • Centralized
    • “Rescue Centers” – Ambulances are concentrated in central ambulance dispatch centers (vs. Fire Departments – Regionalized)
      • Centers are staffed by physicians
      • Can provide prehospital care only (Hangzhou), or resuscitation, inpatient care and transport home (Beijing)
        • Patient may be transported to Rescue Center for resuscitation and admitted into own ICU
        • Competition may exist between Rescue Centers and hospitals
      • Centralization of ambulances may result in increased response times in less-populated areas
  • 5 Prinicpal systems (Hung, 734)
    • Purely prehospital care (Shanghai, Tianjin, Nanjing, Wuhan and Hangzhou)
      • Shanghai
        • No inpatient beds
        • 17 urban Rescue Centers
        • 11 suburban Rescue Centers
        • 168 ambulances
        • Avg. Response Time – 10mins (2003)
    • Independent emergency service center (Beijing and Shenyang)
      • Independent from hospital EDs w/similar capabilities
      • Equipped w/own ED and ICU
    • Prehospital care supported by general hospitals (Chongqing, Chengdu, Qindao and Haikou)
      • No separate Rescue Centers
      • Services provided by nearby hospitals
      • Ambulances staffed by hospital medical workers
      • Puts heavy load on hospitals
        • Could potentially reduce efficiency of EDs
    • Unified communication command center (Guangzhou and Shenzen)
      • No Rescue Centers for ambulance dispatch
        • Unified communication command center for handling urban calls
        • Call forwarded to nearest appropriate hospital for ambulance dispatch
    • Integrated w/in Fire and Police Departments
  • Specific Agencies
    • Shanghai (Thomas, 153)
      • Shanghai Medical First Aid Station
        • Including 10 urban & 11 suburban substations
          • 517 staff (Medical: 58; Drivers: 23)
        • 2 Advanced Care ambulances
        • 40 “Conventional” ambulances
        • Response times:
          • Urban – 8mins
          • Suburban – 30mins
    • Beijing (Thomas, 154)
      • Beijing Emergency Medical Center (est. 1988)
        • “Multi-specialty emergency care center for both out-of-hospital and hospital emergency care services”
        • Not designated as hospital
        • Heliport
        • Accommodations for 40 ambulances
        • Capabilities: ICU, hyperbaric, hemodialysis, CT scan, angiogram, EEG,ECG, ultrasound, OR, blood bank
        • 40,000 reported runs in 1995
    • Ghanzhou (Thomas, 154)
      • “unified municipal EMS dispatching center, with various EDs within the city providing out-of-hospital care in their catchment regions”
      • 1993 – set up first Chinese HEMS
    • Chongqing (Thomas, 154)
      • “the largest city in the world, has one hospital responsible for all emergency and out-of-hospital care services”
    • Hangzhou (Thomas, 153)
      • 35 provincial hospitals
      • 51 community hospitals
      • 20 community clinics
      • Hangzhou Rescue Center
        • City-based, out-of-hospital care provider
        • 600 calls/month for service population of 1.5 million (urban) and 5.5 million (rural)
        • 14 non-stocked ambulances
        • Staffed by either physician or driver


Thomas TL, Clem KJ: “Emergency Medical Services in China.” Academic Emergency Medicine 1999;6:150-5.


Lead Agency

  • Ministry of Public Health


Funding

  • Funding of prehospital services largely relies on government
    • Rescue Centers are principally funded by provincial & city bureaus of Public Health (Hung, 732)
  • “Fee-for-service”
    • Individual Rescue Centers collect for treatment and transport
    • Money used to support operations and staffing costs
    • “Most ambulance centers require payment up front and patients reportedly use ambulances only for perceived emergencies” (Thomas, 153)
    • “Medical insurance does not routinely cover out-of-hospital transport, although it may determine the patient destination” (Thomas, 153)


Levels of Care

  • Physicians, registered nurses and drivers
    • “Ambulance physicians practice EMS medicine full-time because there is no overlap between physicians assigned to EMS or EM” (Thomas, 152)
    • “Generally a shortage of staff working in prehospital emergency systems, which is often attributed to differences in salary
    • “Common for newly graduated doctors to work in prehospital care, although some have undertaken higher level education including master degrees” (Hung, 733)
      • “Standards of care can be variable as the focus of basic medical training is not on prehospital care” (Hung, 733)
      • National Prehospital Emergency Care Training Center
        • Since 1993 has conducted EMS training courses for physicians
        • Approx 90hrs of training (10-15 days)
  • “No providers at the [EMT] or paramedic level, and the concept of transferring specialized EMS skills to nonphysician out-of-hospital personnel is not universally accepted” (Thomas, 152)
  • Henan Province (Hung, 733)
    • Highway Trauma Rescue Group
      • 1 surgeon, two experienced RNs, orderly, driver
  • Shenzhen (Hung, 733)
    • Prehospital MDs and RNs rotate every 3 months from ED (except if ≥45yrs, or unable to work d/t health)
    • Expected to perform intubation, CPR and defib, bleeding control, and wound dressing/splinting
  • Ambulances
    • Wide variation in type and model
  • Equipment
    • “Since all physician calls have intensive care potential, equipment needs increase further” (Thomas, 153)
    • However, equipment supplies are often insufficient
    • Physicians collect necessary supplies from Rescue Center central room
      • “Oxygen, medications and monitors are not pre-stocked”


Education & Training

  • “Currently no specialist training or qualification in prehospital care and there is no training syllabus, professional examination or specialist registration” (Hung, 733)
  • Chinese out-of-hospital education is in its infancy and a further definition of long-term goals would lead toward an appropriate curriculum” (Thomas, 154)


Dispatch & National Emergency Telephone #

  • 120 – directly connected to Rescue Center for physician dispatch
    • Access to care affected as not every household has a telephone


Medical Direction

Emergency Care & Emergency Medicine

  • 1950s – Development of EM begins
  • 1987 – Society of Emergency Medicine under Chinese Medical Association for Emergency Medicine (CAEM) is established
    • “Leading academic organization to expedite EMS development in China” (Thomas, 151)
    • 1990 – Chinese Journal of Emergency Medicine


Disaster

  • Sichuan Earthquake – Chengdu, 2008 (Hung, 735)
  • Provided great deal of understanding as to needs disaster response
    • Search and Rescue
    • Prehospital Emergency Response
  • “Generally observed that not enough resources have been provided for the development of disaster response”
    • Disaster response command center unable to coordinate sufficient amount of medical response in initial period
    • Shortage of experienced personnel in prehospital care and disaster response
    • Communication failures with field rescue teams
    • Medical response team training and equipment inadequate, and lack of resuscitation equipment, communication devices and personal protective equipment
    • “Currently there is a heavy reliance on individual hospitals which the lack the ability to rapidly deploy”


Future

  • “There is tremendous pressure on the Chinese EMS system to provide service for the rapidly expanding, dense population. Out-of-hospital-care, however, is still in a formative stage and it remains uncertain how soon it will be available for the majority of China” (Thomas, 154)
    • “Standardization of medical care, equipment, education, and training would further advance EMS development” (Thomas, 154)


References


Links



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