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FAQ about ER system

In Japan, emergency medical care is categorized into primary, secondary, and tertiary care. What do they each represent?

In Japan, emergency medical services that hospitals provide are categorized into three levels according to their capabilities.

Primary emergency care
represents care provided to patients with low-acuity conditions who can be safely discharged home.
Secondary emergency care
represents care provided to patients with moderate-acuity conditions who require admission to a regular inpatient bed.
Tertiary emergency care
represents care provided to patients with high-acuity conditions who require admission to the intensive care unit.

What is the problem with this three-level model of emergency medicine?

While emergency care providers expect to treat only those patients who fit into their level of care, patients who need emergency care often cannot know which level of hospitals they should visit, as they do not have the ability to categorize or triage themselves into these three levels. This discrepancy is the problem.

Doesn't the referral system, in which high-acuity patients presenting to primary or secondary emergency care facilities promptly are transferred to tertiary care centers, solve such inconveniences?

Although such a referral system exists, it does not function well for two major reasons. First, it is difficult to immediately identify patients who actually are in much more serious conditions than they seem to be in. Second, most tertiary care centers will not accept patients unless they definitely are diagnosed as high-acuity patients. Although the primary, secondary, and tertiary care centers are efficient in treating patients within their acuity levels, they are not well-trained in advanced triage and, therefore, often have difficulties in distinguishing among the three levels at early stages.

What types of emergency medicine systems currently exist in Japan?

Currently, institutions in Japan adopt different systems. However, they can be categorized broadly into three groups. First, Japanese emergency medicine systems can be divided into "Critical care" and "Emergency primary care." The latter type can further be divided into "ER-style emergency medicine" and "Multi-specialty emergency medicine." The critical care system is utilized only at tertiary care centers.

Classification of Emergency Medicine Systems in Japan

  1. Critical care
  2. Emergency initial care
    1. ER-style
    2. Multi-specialty-style
EM system Location Description
Critical care Intensive care unit Care focused on high- severity inpatients; not involved in initial care
ER-style Emergency department Emergency physicians provide initial care, regardless of patients' conditions.
Multi-specialty-style Emergency department and inpatient wards Specialists provide initial and inpatient care to patients of their own specialties.

What is the critical care system?

The critical care system focuses on tertiary-level patients. It usually does not involve initial care or advanced triage. According to current statistics, tertiary-level patients account for fewer than 5% of all patients presenting to the ER in Japan.

What is the ER-style system?

The ER-style system is named after the emergency medicine system developed in the United States of America. Emergency physicians working in the ER-style facilities take care of patients, regardless of their conditions. Walk-in patients first are seen by triage nurses, who assess urgency of their conditions. Those who are triaged as having high acuity are prioritized and seen by the emergency physicians first. Those requiring admission then are referred to different departments by the emergency physicians. Emergency physicians are not involved in inpatient care. The "emergency initial care" the emergency physicians are involved in refers to diagnosis, initial care, and advanced triage (disposition). Advanced triage (disposition) refers to redirecting the patient after initial care in the ER. This includes deciding whether to discharge, observe, or to admit; and in the case of an admission, to which specialty.

What is the multi-specialty system?

The multi-specialty system, as the name implies, is a system where the emergency department is staffed with physician specialists from different departments. Each department assigns one or more physicians to attend the emergency department. In this system, an intern or a nurse sees the patient first, then assigns the patient to a particular department. These nurses are not triage nurses and usually, they are given no special training for such assignment. Currently in Japan, this is the most popular style.

What is the main difference between the ER-style and multi-specialty emergency department?

The main difference is whether there are emergency physicians or not. As opposed to the ER-style emergency department, which is staffed by emergency physicians who are trained to stabilize and treat patients, regardless of their conditions, physicians in the multi-specialty-style emergency facilities treat only patients of their own specialties. In the latter system, it is very common that those who first see patients are unsupervised interns or nurses, and having no systematic training for patient assessment, they often have to rely solely on their "empirical intuition" to decide to which specialist a patient needs to be directed. Problems arise when the patients are misdiagnosed and mis-assigned, or when a patient has multiple problems that involve several departments, as often is seen in trauma cases. A patient may be sent to a wrong department or pushed around among departments. Here, we see the major limitations of this system.

Currently in Japan, there is no clear consensus on the definition of an emergency physician or an ER doctor, and the difference between emergency physicians and those who specialize in other areas and are just in charge of emergency patients sometimes is not clear. Therefore, institutions that have an emergency department may call themselves "ER-style," regardless of whether they are staffed by emergency physicians. The solution to this problem is to emphasize and clarify the definition of an emergency physician. This also leads to clarification and better recognition of the ER-style emergency department.

What does an emergency physician or an ER doctor do?

Emergency physicians or ER doctors are specialists trained to provide initial treatment to patients with all kinds of medical conditions. They are vital for realization of ER-style emergency medicine. However, in Japan, their number is still too small, and the future of the specialty is still uncertain. For Japanese emergency medicine, how to increase the number of emergency physicians is a crucial issue that must be addressed.

Below is a list of characteristics of an ER doctor:

  • limited to working in the ER and not in other specialties.
  • not involved in surgeries, inpatient care, or specialized outpatient clinics.
  • has the ability to provide primary care for patients, regardless of their conditions.