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Pre-hospital Emergency Medical Care – A gateway to health care system?

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Introduction

Historically, global health policy emphasized multiple, vertically oriented programs that concentrated on maternal health and the control of communicable childhood diseases (1).This resulted in major public health agencies focusing their support on selective programs that address priority diseases and activities

(2).Unfortunately, vertical programs do not encourage the development of strong and efficient health care delivery systems. The weakness of this approach is most apparent during crises, such as medical emergencies or incidents involving large numbers of casualties

Prehospital emergency medical care

The purpose of prehospital emergency medical care is to stabilize patients who have life- threatening or limb-threatening injury or illness out of hospital. In contrast to preventive medicine or primary care, emergency medical care focuses on the provision of immediate or urgent medical interventions. It includes two major components: medical decision-making, and the actions necessary to prevent needles death or disability because of time-critical health problems, irrespective of the patient’s age, gender, location or condition.

Prehospital emergency medical care and health system performance

The three fundamentals functions of a health system are to improve the health of the population, respond to people’s expectations, and provide financial protection against the costs of ill-health 9. Prehospital Emergency medical care can contribute positively to these functions. There are no empirical data on the number of lives or disability-adjusted life-years (DAILYs) saved through emergency medical care. Nevertheles, it is clear that many of the conditions that contribute to the burden of disease in Kenya can be mitigated through prompt treatment.10

Enhancing a health system’s responsiveness to people’s expectations lead to improved utilization of services and better outcomes.10 Access to medical care for urgent or life- threatening conditions is a key expectation in many communities. In Kenya mostly in rural areas and in urban centre people use their primary health care centre more often for medical emergencies than for preventive services, such as family planning or prenatal care11.in most instances they use traditional home remedies for minor ailments but turned to primary care medical facilities for acute complaints or when a child seemed seriously ill.

The role of prehospital emergency medical care in providing financial protection against the costs of ill health is complex. The onset of an acute illness or injury forces many families in Kenya to choose between risking financial ruin because of medical expenses or risking death or life long disability attribute to lack of medical care. Both outcomes can have a catastrophic long-term impact.12

Prompt access to care during an emergency is essential, irrespective of whether the system gives financial protection through prepayment options, government provision of health care, or other insurance schemes.12

Core components of prehospital emergency medical care

Prehospital emergency medical care has three components: care in the community; care during transportation, which is related to the question of access; and care on arrival at the receiving health facility. It is designed to overcome the factors most commonly implicated in preventable mortality, such as delays in seeking care, access to a health facility, and the provision of adequate care at the facility.13

Pre-Hospital emergency medical care in the community

The outcome of acute illness or injury is strongly influenced by early recognition of its severity and the need for medical intervention.14 Since most emergencies start at home, any system to promote the early recognition of emergency conditions should be based in the community. 15 In order to save the lives of pregnant women it is important to reduce delays in accessing health care16 and this can happened if we invest in prehospital emergency medical care the provision of well-equipped ambulances for emergencies and employing Registered Paramedics.

Many of of the benefits of prehospital emergency medical care could be realized by training more paramedics. County governments should allocate funds and buy modern ambulances stationed at strategically positioned ambulance stations. Other benefits of prehospital emergency medical care are that it can reduce time wastage at the accident and emergency department in the hospital. Professional prehospital emergency care helps to identify patients with acute need for treatment, identifying serious complications and can refer road accident victims who are seriously injured to higher levels of care immediately. Similarly, prompt referral of severely ill children to advanced health services can reduce child mortality. Many of the benefits to provide quality emergency medical care and patient safety will be realized by supporting professional prehospital providers and allocating funds to support prehospital emergency medical care. Efforts of a sufficient working EMS system could be a further step to the implication of a universal health coverage strategy in Kenya. Further more it may be possible to reduce mortality rates noticeable.

Prehospital emergency medical care and transportation

An absence of emergency medical transport is a common barrier to care.17 This may arise because of several factors including the lack of well-equipped modern ambulance, untrained staff not competent in prehospital emergency medicine, the absence of inadequacy of roads, and the ability to pay for ambulance services.17 The consequences of a lack of transport can be grave. In Kenya many acutely ill or injured patients die either on the way to hospital or at the hospital while waiting to be admitted in the accident and emergency department or in the reception area of an outpatient hospital.18

There is empirical evidence that providing emergency transport saves lives. Developing a well- structured emergency medical services response, better communication system between pre- hospital emergency care and receiving hospitals.19

The prevailing models of emergency medical transport used in Kenya are quite costly and would be impractical for communities who can’t afford. Poor condition of roads, lack of ambulance availability may dictate the utilization of a wider range of options. For example we have witnessed critically ill patients in Kenya being taken to a hospital using wheelbarrows as mode of emergency transportation of the weakest links in the system.

Conditions of many seriously ill or injured patients arriving at the clinics or hospitals end up not recognized. Instead of receiving immediate emergency care patients sometimes keep waiting for long periods of time before being given proper treatment. This results in avoidable deaths and disability. Late patient referral to tertiary care lead to many preventable deaths, poor triage of incoming patients and inadequate provision of emergency care jeopardize the lives of arriving patients at many hospitals over Kenya. Majority of County hospitals in Kenya do not have an adequate triage system. Inappropriate or delayed triage of cases, poor clinical assessments, and potentially harmful delays are only some of the negative factors during the treatment process.

Prehospital emergency medical care and referral facilities

The readily availability of treatment in the prehospital care is the first component of emergency medical care.17

In addition to supplementing the knowledge and skills of professional providers at prehospital care the Kenyan government through parliament and senate should consider passing a emergency medical care bill that will recognize prehospital emergency care as key function allied to the health care system in Kenya. By ensuring registered paramedics take charge in community paramedicine practice the healthcare accessibility for citizens especially in rural areas could be increased.20

At the other end of the spectrum, attention should be given to education received by paramedics. 21, 22 There is a marked disparity between what is taught in medical schools and what is expected of medics in Kenya. Most medical students in Kenya acquire their training and skills on in patient wards of large hospitals in urban areas, where emphasis is placed on making the right diagnosis then on the principles of triage and emergency management.

However, this model does not prepare medics in Kenya to work in prehospital care set up. For county hospitals in Kenya, the most pressing requirement is to sort sick patients and make appropriate triage and treatment decisions. In order to do this well, doctors and nurses need to be trained to recognize the severity of illness and to categorize conditions in relation to the likelihood of a threat to life, treatment priority, and the strategies most likely to maximize outcome, rather than on the basis of precise diagnoses. The training of healthcare providers in this manner requires a critical mass of physicians, nurses and paramedics who understand the principles of emergency care and are prepared to exert pressure for their inclusion in curricula of their respective disciplines. 23

The measures described are not particularly expensive if well-structured and can benefit large numbers of patients. However; cost is still likely to represent a formidable barrier to implementing emergency medical care systems in Kenya. Depending on the extent of Counties health care infrastructure, the implementation of an effective emergency medical care system will require little or more than incremental reforms, or it may demand a major overhaul of the health care system.24

Conclusion

Health care in Kenya has not traditionally focused on prehospital emergency medical care. A sufficient prehospital care for acute illnesses and injuries is essential for good outcomes.

Although health promotion and disease and injury prevention should be core values of any health system, many acute health problems will continue to occur. The incorporation of prehospital emergency medical care into health care systems could have a significant impact on the well-being of Kenyans and decrease the long-term human and economic costs of illness and injury.

The priority should be placed on developing minimum guidelines for emergency medical care over the 47 counties in Kenya. The efficiency of such care could be assessed by implementing pilot programs in some counties. This would help to determine the degree to which prehospital emergency medical care systems save lives and at what cost. Prehospital emergency medical care remains to be the gateway to the healthcare system all over the world. Universal health care coverage is not possible without a proper prehospital emergency medical care system.

References

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13 Balikuddembe, J.K., Ardalan, A., Khorasani-Zavareh, D. et al. Weaknesses and capacities affecting the Prehospital emergency care for victims of road traffic incidents in the greater Kampala metropolitan area: a cross-sectional study. BMC Emerg Med 17, 29 (2017). https://doi.org/10.1186/s12873-017-0137-2

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BMC Health Serv Res 16, 39 (2015). https://doi.org/10.1186/s12913-016-1282-0

21 Lincoln EW, Reed-Schrader E, Jarvis JL. EMS Quality Improvement Programs. [Updated 2020 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536982/

22 Michau, R., Roberts, S., Williams, B. et al. An investigation of theory-practice gap in undergraduate paramedic education. BMC Med Educ 9, 23 (2009). https://doi.org/10.1186/1472-6920-9-23

23 Mackway-Jones K, Carley SD, Morton RJ, Donnan S. The best evidence topic report: a modified CAT for summarising the available evidence in emergency medicine. J Accid Emerg Med. 1998 Jul;15(4):222-6. doi: 10.1136/emj.15.4.222. PMID: 9681304; PMCID: PMC1343127.

24 Kenya Emergency Medical Care Policy 2020-2030, Ministry of Health – Republic of Kenya

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