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What's an ER?


The General Practitioner or "Kaigyou-I" was the main provider of Emergency/Acute care until 1960ís. They took Emergency calls from their patients and family and made house calls if necessary. As the infrastructures for transportation developed, an increase in serious injuries from motor vehicle collision happened. About this time, advances in technology made necessary medical care more hospital based rather than patientís home based. These changes led to the initial organization of the Emergency/Acute care system in Japan.

With the advent of safety devices such as seat belts and air bags, Japan as well as other countries has enjoyed a reduction of serious injuries. On the other hand, Japan enjoyed longest life expectancy in the world over the last several decades that resulted in dramatic increase in their older population. These advances prompted more changes in the Emergency/Acute Care system in Japan.

Current System-EMS:

The most critically ill or injured has been the emphasis of Emergency/Acute Care in Japan since 1960ís. The system was set up to better utilize resources and EMS by triaging patients depending on their acuity of the problem. There are three different levels of designated Emergency Care in Japan:

  1. "Primary Emergency Care"-provide patients with low-acuity conditions who can be safely discharged to home
  2. "Secondary Emergency Care"-provide patients with moderate-acuity conditions who require admission to a general inpatient bed
  3. "Tertiary Emergency Care"-provide patients with high-acuity conditions who require admission to the intensive care or emergency surgery

In major metropolitan areas, each medical facility has a designation of which level of Emergency Care they can provide and accept patients from EMS accordingly.
However, in rural areas where the population is low and resources are limited, this designation does not seem to matter much.

Current System-Hospitals:

Major teaching hospitals such as public hospitals in major metropolitan areas and University Hospitals tend to provide "Tertiary Emergency Care" and in some instances exclusively "Tertiary Emergency Care". The idea here is again to utilize resources more effectively and be able to provide timely care for the most critically ill or injured without being crowded out by lower acuity patients. Those hospitals also tend to have critical care beds to provide continuing cares. In another words, the same staff who take care of these high acuity patients initially, will continue to take care of them in their ICU. Some people refer this model as "ICU style" and still the main stream in Japan.

Hospitals that provide "Primary and/or Secondary Emergency Care" tend to be smaller hospitals in major metropolitan areas or hospitals in smaller communities. They frequently have their own inpatients beds that they admit to.

The increasing trend has been to adopt "ER style" which is quite EMS friendly.

Current System-Providers/Doctors:

The ED staffing has been historically based on a "Multi-Specialists Model" with Specialist Physicians representing different services and a Nurse or Intern directing to whichever services seems most appropriate based on the presenting complaints in the "Tertiary Emergency Care" providing Hospitals.

In smaller Hospitals, on call Physicians on a rotation basis or Resident Physicians provide treatment. Their specialty can be Primary Care or non-Primary Care Specialties.

Dedicated Emergency Physicians who have expertise in resuscitation and all disciplines of acute care have been emerging recently and the number of training program have been increasing.

The number of Physicians involves in "ICU Style" are roughly 1000 and in "ER style" are roughly 500.

Issues and Concerns:

  1. Triaging to appropriate provider may not be easily done in the ambulance. This is especially true in cases of non-trauma.
  2. The "Multi-Specialists Model" and "ICU style" of providers has advantage of continuity of care, but this requires providerís long working hours and risks possible human errors. Some patients with conditions requiring multi specialty care may also benefit from good generalist oversight with specialist consults.
  3. The "Multi-Specialists Model" and "ICU style" of providers are also resource intensive, in other words require more Doctors. This means less flexibility in taking patients. For example, if an incoming patient requires a particular specialist who is tied up in the OR, this becomes a reason for ambulance diversion. Or an on call Doctorís specialty happens to be not the one seemingly related to this particular patient, then that also becomes a reason for ambulance diversion.

Work so far and future direction:

"The ER Committee" has 12 board members and more than 100 active members all over Japan and US. "ER-style Emergency Medicine" has been one of the active topics in the Annual Meetings of the Japanese Association for Acute Medicine. It is also one of Six "Panel Discussion" topics in the 37th Annual Meeting of the Japanese Association for Acute Medicine in 2009.

"The ER Committee" has published annual reports since 2004. It also reported status of "ER-style" in Japan in JJAAM: Journal of Japanese Association for Acute Medicine, 2007; 18:644-651 and 2008; 19:416-23. Its web site has provided basic information to layperson, and more specialized information including educational resources and training programs to health care workers.

Better characterization of needs and barriers for "ER-style" in Japan would be a next step. Figuring out appropriate staffing and other logistics of running ED may be another topic to work on. In order to avoid pitfalls found in the US such as ED overcrowding issues and shortage of Emergency Physicians especially in rural areas, it is very important for "the ER Committee" to work together with others in medical communities and government to form sound strategies to fit the needs of each community in Japan.