doi: /ams2.154

Transcription

1 Acute Medicine & Surgery 2016; 3: doi: /ams2.154 Original Article Emergency medicine as a specialty in Asia Jen Heng Pek, 1 Swee Han Lim, 1 Hiu Fai Ho, 2 T. V. Ramakrishnan, 3 Sabariah Faizah Jamaluddin, 4 Faith Joan C. Mesa-Gaerlan, 5 Mohan Tiru, 6 Sung Oh Hwang, 7 Wai-Mau Choi, 8 Somchai Kanchanasut, 9 Pairoj Khruekarnchana, 9 Levent Avsarogullari, 10 Takeshi Shimazu, 11 and Shingo Hori 12 1 Department of Emergency Medicine, Singapore General Hospital; 6 Department of Emergency Medicine, Changi General Hospital, Singapore; 2 Accident and Emergency Department, Queen Elizabeth Hospital, Hong Kong; 3 Department of Accident and Emergency Medicine, Sri Ramachandra Medical College and Research Institute, Chennai, India; 4 Emergency and Trauma Department, Sungai Buloh Hospital, Sungai Buloh, Malaysia; 5 Department of Emergency Medicine, Philippine General Hospital, Manila, Philippines; 7 Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, Seoul, Korea; 8 Department of Emergency Medicine, Mackay Memorial Hospital, Hsinchu, Taiwan; 9 Emergency Department, Rajavithi Hospital, Bangkok, Thailand; 10 Department of Emergency Medicine, Erciyes University Medical School, Kayseri, Turkey; 11 Department of Traumatology and Acute Critical Medicine, Faculty of Medicine, Osaka University, Osaka, Japan; 12 Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan Aim: We aim to examine the similarities and differences in areas of EM development, workload, workforce, and capabilities and support in the Asia region. Emerging challenges faced by our EM community are also discussed. Methods: The National Societies for Emergency Medicine of Hong Kong, India, Japan, Malaysia, Philippines, Singapore, South Korea, Taiwan, Thailand and Turkey participated in the joint Japanese Association of Acute Medicine (JAAM) and Asian Conference of Emergency Medicine (ACEM) Special Symposium held in October 2013 at Tokyo, Japan. The findings are reviewed in this paper. Results: Emergency medicine (EM) has over the years evolved into a distinct and recognized medical discipline requiring a unique set of cognitive, administrative and technical skills for managing all types of patients with acute illness or injury. EM has contributed to healthcare by providing effective, safe, efficient and cost-effective patient care. Integrated systems have developed to allow continuity of emergency care from the community into emergency departments. Structured training curriculum for undergraduates, and specialty training programs for postgraduates are in place to equip trainees with the knowledge and skills required for the unique practice of EM. Conclusion: The practice of EM still varies among the Asian countries. However, as a region, we strive to continue in our efforts to develop the specialty and improve the delivery of EM. Key words: Asia, emergency medicine, specialty INTRODUCTION INTEGRATED SYSTEMS OF Emergency Medicine (EM) care did not exist prior to the 1960s. 1 Pre-hospital care meant little more than rapid transportation of patients to Corresponding: Jen Heng Pek, MBBS, Swee Han Lim, MBBS, Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore jenheng.pek@ mohh.com.sg, lim.swee.han@sgh.com.sg. Received 1 Jun, 2015; accepted 2 Jul, 2015; online publication 27 Aug, 2015 hospitals. The emergency room serves as a reception for patients coming to the hospital. There were also no organizations responsible for provision of high quality emergency medical care and to advance the science and art of its delivery. There were no specific training programs for physicians and nurses. Staffing within the emergency departments was distributed among physicians of various specializations and level of training. The end result was erratic emergency departments with dismal patient outcomes and minimal benefit to public health. Forty years on, EM has evolved into a discipline with a unique set of cognitive, administrative and technical skills 65

2 66 J.H. Pek et al. Acute Medicine & Surgery 2016; 3: for managing all types of patients with acute illness or injury. The Emergency Department has transformed from a receiving room in the hospital to a focal point of clinical care and research on time-sensitive medical conditions such as myocardial infarction, severe trauma, sepsis and stroke all of which require early diagnosis and early initiation of definitive treatment. Delivery of EM care today has a structured training curriculum and is largely coordinated through integrated systems to allow continuity of emergency care from the community at the pre-hospital level, and into emergency departments. In 2011, Holliman et al. identified publications that supported the efficacy or value of EM as a medical specialty and of the clinical care delivered by trained emergency physicians. The review concluded that EM is a distinct and recognized medical specialty with its own specialist training programs (residencies), and there is supportive literature for the following statements: 2 1. EM is an important key component for all national healthcare systems. 2. EM and care rendered in emergency departments offer many efficiencies and cost effectiveness of care delivery within the broader healthcare system. 3. EM and emergency departments can provide a number of effective Public Health and Preventive Medicine measures. 4. EM residency training results in improved patient care in the ED. 5. EM faculty can deliver high-quality patient care and medical training, and are effective for patient safety. 6. Trained emergency physicians can effectively and safely provide critical care and perform selected invasive procedures. 7. Trained emergency physicians can safely and effectively manage trauma patients and perform advanced airway management. 8. Trained emergency physicians can accurately interpret electrocardiograms. 9. Trained emergency physicians can accurately and safely interpret radiographic studies. 10. Trained emergency physicians can safely and accurately perform and interpret ultrasound studies, both diagnostic and procedure-related. Overall, EM plays a significant role in the healthcare by contributing to effective, safe, efficient and cost-effective patient care. However, within Asia, the initiation, awareness of the value of EM, along with its acceptance and subsequent pace of development of emergency medicine vary widely beyond our geographical and cultural differences. This article shall explore our similarities and differences as a specialty. Fig. 1. Demographics. METHODS THE NATIONAL SOCIETIES for Emergency Medicine of the countries that are represented included Hong Kong, India, Japan, Malaysia, Philippines, Singapore, South Korea, Taiwan, Thailand and Turkey (Fig. 1). These countries participated in the joint Japanese Association of Acute Medicine (JAAM) and Asian Conference of Emergency Medicine (ACEM) Special Symposium held in October 2013 at Tokyo, Japan. The key findings of the symposium are reported in this paper. RESULTS Development of emergency medicine WITHIN ASIA, EM was first recognized in Singapore in In the early days, those who recognized the need for EM and decided to stay on had to learn from the other specialties given the wide scope of practice. As the specialty took off, doctors, nurses and other supporting staff went to the USA and UK, which had an established and integrated EM system to gain hands-on experience. When they returned, they took on training of their juniors. The pioneers then worked towards establishment of postgraduate examinations for trainees targeted at assessment of cognitive and specific technical skills required for the practice of EM. Areas of sub-specialization of EM are then identified for development, which includes emergency cardiac care, emergency trauma care, emergency toxicology, pre-hospital emergency care, pediatric emergency medicine, disaster medicine, and observation medicine. National societies consisting of EM physicians have also been set up. These societies are dedicated to the improvement of EM practice via research and education, and influence health policy through forums, publications, inter-organizational collaboration, policy development, and consultation services for physicians, teachers, researchers and students (Table 1).

3 Acute Medicine & Surgery 2016; 3: Emergency medicine in Asia 67 Table 1. Development of emergency medicine (EM) Year EM recognized Year post graduate exams established Year national society of EM established Singapore Philippines Turkey South Korea Hong Kong Taiwan Malaysia Japan (1983 quasi-board 1973 certification) Thailand India The Japanese Association for Acute Medicine (JAAM) was the first society for Emergency Medicine that was established in Asia. JAAM was founded in 1973, with improvement of care for critical trauma patients in traffic accidents as the main aim for its establishment. 3 Being the first established professional association of emergency physicians in Japan, JAAM had a great impact on policymaking by bureaucrats in the government. A specialty board was subsequently set up in the 1980s. Emergency medicine work load Emergency department attendance Over the years, the demand for EM services continues to exceed increases explained by growth, leading to issues of overcrowding, which has been linked to a range of adverse outcomes for patients and staff, including increased medical errors, increased patient mortality, patient dissatisfaction, high levels of work-related stress, decreased morale among ED staff and decreased capacity of EDs to respond to mass casualty incidents. 4 While the majority of the attendance remains unplanned, easier accessibility to emergency services has contributed to overcrowding as patients come to the Emergency Department for primary healthcare services after office hours. Most EDs operate 24 h a day, with staffing levels matched to patient volume. The exception to this in Asia includes Japan, Malaysia and South Korea. This is either due to small hospital size or lack of emergency physicians within the hospital to support 24-h ED coverage. In some countries, emergency departments have become important entry points for those without other means of access to medical care. As such, ED generally cannot refuse to accept patients (without proper transfer arrangements) in Asia with the exception of certain centers in Japan and Thailand. Emergency medicine work force Emergency doctors While the case mix of patients may vary in different centers depending on location and type of facility, doctors in the ED have to deal with patients with varying presentations and acuity. Importantly, patients do not arrive to the ED with a diagnosis, hence the search for diagnosis and management often happens concurrently. With advancement and availability of medical technology, we are now able to detect and treat many life threatening medical conditions that were once difficult to diagnose and manage. This has made the practice of EM more gratifying for the doctors and safer for the patients. Doctors in ED must be adept in both routine diagnosis and high-speed emergency care. This involves the skills and broad knowledge of all branches of medicine to recognize the most serious cases, stabilize the patient s condition, order tests and direct others in providing the necessary care. While most emergency physicians practice solely emergency medicine, some emergency physicians from Hong Kong, Indian, Japan, Taiwan and Thailand are also involved in the practice of other specialties. For instance, some of these specialties include intensive care and community medicine in Hong Kong; general surgery, neurosurgery, anesthesia in Japan; and internal medicine, general surgery, cardiology and pediatrics in Taiwan. Within Asia, the number of per doctor ranges from 395 in Taiwan to 37,167 in Philippines. However, with the increasing attendances to the ED, the demand for certified emergency physicians remains high. In Malaysia (Selangor), Philippines and Thailand, this crosses 100,000 persons per certified emergency physician (Table 2).

4 68 J.H. Pek et al. Acute Medicine & Surgery 2016; 3: Table 2. Emergency doctors Number of per doctor Number of per ED doctor Number of per certified ep Thailand 1,383 16, ,714 Philippines 37, ,886 Malaysia Kuala Lumpur 622 1,242 23,013 21,600 96, ,000 Selangor Turkey ,386 88,235 South Korea ,728 Singapore ,368 46,286 Japan ,656 35,444 Hong Kong ,333 25,914 Taiwan ,105 16,285 India No data provided as there is no approved national data. ED, emergency department. Data presented based on city, data does not include private and two university hospitals. Population includes Kuala Lumpur and Petaling Jaya both under Hospital Kuala Lumpur emergency medical service (EMS). No data available. Includes only tertiary level hospitals. Table 3. Emergency nurses Nurses per 1,000 Percentage of emergency nurses (%) Japan Singapore South Korea Taiwan Hong Kong Thailand Turkey Malaysia Kuala Lumpur Selangor Philippines Percentage of certified emergency nurses (%) India No data provided as there is no approved national data. Only in tertiary level hospitals. No data available. Data presented based on city, data does not include private and two university hospitals. Population includes Kuala Lumpur and Petaling Jaya both under Hospital Kuala Lumpur emergency medical service (EMS). Emergency nurses The nature of work within the ED also offers variety and complexity to the nursing team. Nurses in the ED are involved in the care of patients during the critical phase of their illness or injury and may frequently come into contact with the patient before the physician. As such, emergency nurses must combine intellectual and technical skills to make prompt decisions and actions. Rapid and early recognition of life-threatening illness or injury, and the use of advanced monitoring and treatment equipment are important skills required for the emergency nurse. In some institutions, the nurses can also be involved in the ordering of tests and medications according to departmental protocols that have been set up to enhance patient care. 5 Within Asia, the proportion of nurses working in the ED ranges from 1.1% in Japan to 15.0% in Philippines. However, the data on the number of certified emergency nurses remain scarce, with a range of 0.05% to 1.20% of all nurses having undergone formal training and demonstrated competency via formal certification processes (Table 3). Emergency medicine capabilities and suppport Emergency medical services The emergency medical service (EMS) systems across Asia have a short history of less than 15 years. With development of EM, many Asian countries have begun shifting focus to the importance of having an optimal EMS system. Ambulances remain a main form of transportation for rapid transfers of patients to the ED. Newer designs with enhanced capabilities with the aim of improving patient survival are available. The per ambulance ranges from 2,106 in Philippines to 207,360 in Singapore. Ambulance crews are trained to provide treatment en route as per country- or institution-specific protocols. The percentage of paramedics (with various levels of training) among the EMS personnel ranges from 0.06% in Philippines to 72% in Thailand (Table 4). Pre-hospital care is provided by ED staff in India, Malaysia, Thailand, and for selected cases in Philippines. In Japan, ED staff may be involved in pre-hospital care for long distance transfer only. Ong MEH et al., having compared the pan-asian resuscitation outcomes study (PAROS) EMS systems from literature review and survey, 6 concluded that the EMS systems, most of which are single-tiered, do not have emergency medical technicians with skills to perform advanced life support procedures. The ambulances are run by public services (fire-based). Most systems do not have physicians on board the ambulances, thus the need for medical direction and oversight, which have not been established in a systematic manner. 7 There are variations in the presence of a committee for directness of medical oversight, certification and employment of medical control, and location of direction center. While most of these EMS systems use a

5 Acute Medicine & Surgery 2016; 3: Emergency medicine in Asia 69 form of computer-aided dispatch, there is a lack of priority dispatch systems or providing callers with cardiopulmonary resuscitation instructions over the telephone. Furthermore, ambulance response times are affected by the high densities in Asian cities due to traffic congestion and difficulty in accessing patients in high-rise buildings. The deployment of motorcycle first responders in Singapore and Taiwan is a measure directed at reducing response times. Table 4. Emergency medical services (EMS) Population per ambulance Total EMS Personnel Philippines 2,106 3, Thailand 4,745 25, South Korea 6,717 19, Taiwan 22,042 38, Japan 22,240 57, Turkey 26,959 27, Hong Kong 39,000 2,000 5 Malaysia Kuala Lumpur Selangor 160, , Percentage of paramedics (%) Singapore 207, India No data provided as there is no approved national data. Hong Kong has <100 paramedics with Emergency Medical Technician (EMT) III, about 700 with EMT II. Data presented based on city, not country. Hospitals with emergency department and facility available Across Asia, the number of hospitals per million ranges from 1.2 in Malaysia (based on state of Kuala Lumpur) to 66.8 in Japan. Hospitals with emergency department make up 11% in Philippines to 100% in Malaysia (based on state of Kuala Lumpur and Selangor). To deal with acute emergencies within the ED such as acute myocardial infarction, stroke, major trauma and burns, it is essential for hospitals to provide support with the necessary facility and expertise. Refer to Table 5 for the breakdown of hospitals with percutaneous coronary intervention (PCI), fibrinolysis for stroke, trauma center and burn center capabilities by country. All Asian countries are supported by the availability of a poison information center except Singapore. Waiting times for bed Emergency department wait time and length of visit are important measures of the timeliness, efficiency, safety and patient-centeredness of emergency care. Prolonged ED wait time and length of visit can reduce quality of care and increase adverse events for patients with serious illnesses, 8 decrease patient satisfaction, 9 and increase the number of patients who leave before being seen. 10 When patients are admitted to the hospital from the ED, the wait for an inpatient bed can range from 5 h to 168 h (Table 6). During this time, the transitional care of these patients can be under the ED (for Hong Kong, India, Japan, Taiwan and Turkey) or the admitting department (for Philippines) or a joint effort between both departments (for Malaysia, Singapore, South Korea and Thailand). However, for Table 5. Breakdown of hospitals with emergency departments and capability Hospitals per million Total number of hospitals Emergency hospitals (%) PCI (%) Stroke fribrinolysis (%) Trauma (%) Burns (%) Japan ,553 3,932 (46) 1,128 (13) 778 (9) 60 (0.7) 94 (1.1) South Korea , (17) 10 (0.4) 1 (0.04) Thailand ,600 1,200 (75) 45 (2.8) 51 (3.2) 30 (1.9) 10 (0.6) Taiwan (38) 103 (20) 103 (20) 27 (5.4) 27 (5.4) Philippines , (11) 27 (1.5) 20 (1.1) 35 (2.5) 5 (0.28) Turkey ,453 1,395 (96) (3.0) Hong Kong (32) 10 (20) 8 (16) 5 (10) 2 (4) Singapore (50) 12 (86) 12 (86) 6 (43) 1 (7.1) Malaysia Kuala Lumpur Selangor (100) 10 (100) 3 (75) 0 (0) 3 (75) 0 (0) 3 (75) 0 (0) 3 (75) 1 (10) India no data provided as there is no approved national data. No data available. Based on hospitals in City of Kayseri, serving a total of 2,500,000. Data presented based on city, data do not include private and two university hospitals.

6 70 J.H. Pek et al. Acute Medicine & Surgery 2016; 3: Table 6. Waiting times for inpatient bed Hours Within 6 h India (5 h) Within 12 h Thailand (Preferred 8 to 12 h) Singapore (10 h) Within 24 h Malaysia (6 to 24 h) Philippines (6 h for private, 24 h for public) Turkey (24 h) Longer than 24 h Hong Kong (24 to 48 h) Taiwan (168 h) Unknown Japan South Korea patients admitted to Intensive Care Unit, ED is only involved in the care of these patients for more than 6 h in Hong Kong, Malaysia and Thailand. Table 7. Emergency medicine postgraduate training Number of years Months of EM positing (%) 3 Thailand 18 (50) 3.5 Taiwan 20 (47.6) 4 India 18 (37.5) Malaysia 26 (54.2) Philippines 30 (62.5) South Korea 36 (75) Turkey 35 (72.9) 5 Japan 24.5 (40.8) Singapore 35 (58.3) 7 Hong Kong (43 71) Excludes up to 7 months of electives which can include both emergency subspecialty and non emergency medicine postings. Includes 1 month of emergency medical service (EMS), 1 month of Disaster and 1 month Toxicology. Includes 1 month of EMS and 1 month Toxicology. 1 year intern without EM; mandatory 6 months surgery and 6 months non-surgical rotation. Emergency medicine training Curriculum Emergency medicine has been incorporated into medical school curriculum as a compulsory clinical rotation for most Asian countries, with the exception of Thailand where the exposure to EM practice in many centers may be integrated into other specialties. During the rotation, medical students are exposed to the presentation of cases to the ED as well as the shift work environment within the ED, allowing them to gain insight to management and disposition of patients with acute disease presentations, and work habits of ED physicians. 11 As there is no internationally recognized, standard curriculum that defines the basic minimum standards for emergency medicine education, the International Federation for Emergency Medicine has convened a committee of international physicians, health professionals and other experts in emergency medicine and international emergency medicine development, to outline a curriculum for foundation training of medical undergraduates in emergency medicine to address this deficit. 12 The number of years of postgraduation training (including internship) required for EM varies from 3 to 7 within Asia (Refer Table 7). During this period, EM posting makes up 37.5% to 75% of the clinical rotations. Aside from EM and its subspecialties (for instance toxicology, emergency medical services), other core postings common among trainees from various countries include internal medicine (including subspecialties for instance cardiology, respiratory, gastroenterology, neurology etc.), general surgery, orthopedics, obstetrics and gynecology, pediatrics (including pediatrics emergency medicine), intensive care, and anesthesia. Other less common clinical rotations include otolaryngology, ophthalmology, cardiothoracic surgery, neurosurgery, trauma, diagnostic radiology and psychiatry (Refer Fig. 2). The broad based rotations serve to expose the trainee and equip him/her with the knowledge and skills required for the unique practice of EM. Trainees are required to undergo advanced cardiac life support (ACLS or equivalent) and advanced trauma life support (ATLS or equivalent). Pediatrics advanced life support (PALS) and emergency airway management skills are optional for EM trainees in Japan. As EM continues to develop along with medical technology, we have seen the expansion in the clinical use of emergency ultrasound. Focused emergency ultrasound is used to diagnose acute life-threatening conditions, guide invasive procedures, and treat emergency medical conditions, leading to improved patient care. Particularly within Asia, the use of ultrasound supplants other more expensive and limited diagnostic entities. The use of ultrasound by emergency physicians is now widely acknowledged and most countries, with the exception of Philippines, have included emergency ultrasound in the training curriculum. DISCUSSION Challenges in EM FACED WITH THE pressures of increasing health care costs, unavailability of inpatient hospital beds, and increasing use of diagnosis-related groups to cut governmental health expenditure, EDs need to consider more cost-

7 Acute Medicine & Surgery 2016; 3: Emergency medicine in Asia 71 Fig. 2. Emergency Medicine Curriculum Rotation Requirements. X Rotation is part of Emergency Medicine curriculum 1 Optional/variable duration of rotation during core training curriculum 2 Optional rotation after completion of core training curriculum 3 Rotations not specified AN Anesthesia CR Cardiology CS Cardiothoracic surgery DR Radiology EM Emergency medicine EMS Emergency medical service ENT Otolaryngology EYE Ophthalmology IM Internal medicine GS General surgery ICU Intensive care unit NS Neurosurgery NU Neurology OG Obstetrics and gynaecology OR Orthopaedic surgery PD Pediatric PSY Psychiatry RP Respiratory TR Trauma efficient and standardized means of managing emergency patients on an ambulatory basis. 13 Rapid and aggressive diagnostic evaluation and very early initiation of definitive therapies for patients can result in fewer inpatient admissions and shorter lengths of stay for those who are hospitalized, entrenching the very important role of emergency medicine in the care of the acutely sick and injured. While emergency departments are intended for the seriously injured or ill, we now see an increasing number of patients with non-emergent conditions. The emergency department is used as an entry point into the health care system, especially when there is a lack of access to primary care physicians and specialists in a timely manner. 14 As such, there has been an increase in the number of annual ED visits

8 72 J.H. Pek et al. Acute Medicine & Surgery 2016; 3: over the years. However, the numbers of emergency specialists and doctors remain insufficient to deal with this increase in attendance, 15 requiring locum doctors to fill this shortage. While more training posts have been created to increase recruitment, the shortages of trainee doctors remain, as not all positions are filled. Emergency physicians inherit a legacy of stress and burnout, leading to frustration and shortened career span. While the attrition rate for emergency physicians is not known, the issue of work life balance must be addressed to prevent their exodus. Retaining our skilled and experienced emergency physicians will be the challenge over the next few years. When the ED gets overcrowded, the demand for service exceeds the ability to provide quality care in a timely manner. It can be measured by monitoring waiting times required, for instance, from registration to physician consult, and the time necessary to move admitted patients to appropriate inpatient beds. ED overcrowding is a multifactorial problem due to causes such as the lack of inpatient beds for admitted patients (exit block), limited access to primary care and specialists, a shortage of ED staff, increasing complexity and acuity of patients, and a lack of alternative advanced diagnostic testing and treatment facilities. Overcrowding is hazardous for patients as medical errors can arise due to delay in patient care, intensity of decisionmaking, pressure to move patients out quickly from the ED, the lack of monitoring when patients are cared for in hallways and waiting rooms, and the increased stress on caregivers. 16 Overcrowding is also hazardous for the ED itself as it has a detrimental impact on the staff morale. Also, as medicine progresses, there are disease entities that are being recognized or whose therapies have only recently developed. Current EM literature typically focuses on prevalent conditions such as acute coronary syndrome and trauma. EM residency training also focuses on a wide scope of topics covered, making little room for in depth consideration of patients and disease entities less commonly encountered. Without awareness of the new treatments and procedures, the emergency physician may not correctly diagnose and initiate treatment in a timely manner. Furthermore, with aging s and increased longevity for patients following advances in medical therapeutics, emergency physicians have to deal with more geriatrics patients, and also patients presenting to the ED with novel complications of treatments or late stage diseases that have not been seen in the past. 17 Serving as an interface between community and hospital, EDs ideally should have an established and reliable means to move clinical information from and to the community. This shared information between ED, community care providers and other institutions will allow for seamless patient care and improved decision making by providers. However, few health regions have such useful linkages in place for integration of hospital and community care. It is important to note that the outcomes of using electronic medical records have been mixed while keeping electronic medical records does improve the efficiency of physicians and overall quality of care in the ED, it does not reduce patient length of stay and cost of care in the ED, and improve patient satisfaction. 18 CONCLUSION HAVING SEEN HOW EM has developed as a specialty making great strides across the region over the years, EM now stands as a recognized specialty with a pool of trained physicians and established structured training programs. Despite the many challenges, with the passion, drive and sacrifices of those who practice this art, we can be optimistic about her continual development and contributions to the medical field and also the community. Asia is a continent with huge geographic and cultural differences, very much like the ED patients presenting with a spectrum of conditions. Similar to how physicians are expected to identify trivial diseases from the life-threatening ones, triage and deliver effective medical care while striving to meet patients expectations, it is important for us to examine ourselves as a region, to look for ways among our differences and similarities to move forward together as one, advancing emergency care in the region. We hope that our discussion will generate interest and assist in further collaborations in monitoring and improving emergency care in the region and beyond. DISCLOSURE THE AUTHORS DECLARE that there are no conflicts of interest regarding the publication of this paper. REFERENCES 1 Zink B. Anyone, Anything, Anytime. A History of Emergency Medicine. Philadelphia (PA): Mosby, Holliman CJ, Mulligan TM, Suter RE et al. The efficacy and value of emergency medicine: A supportive literature review. Int. J. Emerg. Med. 2011; 4: Hori S. Emergency medicine in Japan. Keio J. Med. 2010; 59: Moskop JC, Sklar DP, Geiderman JM, Schears RM, Bookman KJ. Emergency department crowding, part 1 concept, causes, and moral consequences. Ann. Emerg. Med. 2009; 53:

9 Acute Medicine & Surgery 2016; 3: Emergency medicine in Asia 73 5 Chan GK, Garbez RO. Education of advanced practice nurses for emergency care settings: Emphasizing competencies and domains. Adv. Emerg. Nurs. J. 2006; 28: Ong MEH, Cho J, Ma MH et al. Comparison of emergency medical services systems in pan-asian resuscitation study countries: Report from a literature review and survey. Emerg. Med. Australas. 2013; 25: Shin SD, Ong MEH, Tanaka H et al. Comparison of emergency medical services systems across Pan-Asian countries: A Webbased survey. Prehosp. Emerg. Care. 2012; 16: Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med. J. Aust. 2006; 184: Taylor C, Benger JR. Patient satisfaction in emergency medicine. Emerg. Med. J. 2004; 21: Fernandes CM, Price A, Christenson JM. Does reduced length of stay decrease the number of emergency department patients who leave without seeing a physician? J. Emerg. Med. 1997; 15: Wald DA, Lin M, Manthey DE, Rogers RL, Zun LS, Christopher T. Emergency medicine in the medical school curriculum. Acad. Emerg. Med. 2010; 17 (Suppl. 2): S Hobgood C, Anantharaman V, Bandiera G et al. International federation for emergency medicine model curriculum for emergency medicine. Int. J. Emerg. Med. 2010; 3: Lim SH, Anantharaman V. Emergency medicine in Singapore: Past, present, and future. Ann. Emerg. Med. 1999; 33: American College of Emergency Physicians. The Ethics of Health Care Reform: Issues in Emergency Medicine An Information Paper. June The College of Emergency Medicine. STEP Campaign: Rebuilding the emergency medicine service step by step. Press statement 25 November Working CAEP. Group on the future of emergency medicine in Canada. The future of emergency medicine in Canada: Submission from CAEP to the Romanow Commission. Part 2. CJEM 2002; 4: Arvind V. The challenge for emergency medicine: The next five years and beyond. Emerg. Med. News 2011; Schumacher Group. Emergency department challenges and trends: 2010 survey of hospital emergency department administrators