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TRACK E

Status of Emergency Medicine Around the World- Hong Kong

Dr. LAU Chor-chiuConsultant and Chief-of-Service

Pamela Youde Nethersole Eastern Hospital

Hong Kong

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Hong Kong (Special Administrative

Region)Population 6.787 millionArea 1,102 square Km

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Hong Kong (Special Administrative

Region)LocationSouthern part of Guangdong Province

HistoryBritish Colony from 1842, returned

back to China on 1 Jul 1997

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Hong Kong (Special Administrative

Region)International city predominantly Chinese descent (95%), Cantonese speaking

2001 CensusPopulation 6.7MSex ratio (M/F) 0.956 : 1

Age 0-14 : 16%Age 15-64 : 72%Age > 65 : 11%

(Census and Statistics Department, HK)

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Hong Kong Population Age Pyramid

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Hong Kong (Special Administrative

Region)Socio-economicsEstimated GDP (2002) Eu$146,101mEstimated total public spending on

health care (2001/02) about 2.7% GDP

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Age specific Mortality Rates by Disease Groups 2001 (All

age)Neoplasm 172.8

Diseases of circulatory system 125.6

Disease of respiratory system 82.3

External causes of morbidity and mortality

27.4

Diseases of genitourinary system 21.5

Disease of digestive system 19.3

Certain infections and parasitic diseases 13.8

Endocrine, nutritional and metabolic diseases 11.5

Diseases of nervous system 4.6

Signs, symptoms & abnormal clinical and laboratory findings, not classified elsewhere

4.5

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Health Care SYstem

Public Hospital Authority – manage all all public hospitals,

major health institutes and general out patient clinics since 1 Jul 2003

Government funding and responsible for 95% of medical service

Recent financial reforms A&E charging started since Nov 2003 (approx. Eu$11.5

per attendance, including all investigations and prescription)

In-patient care: Eu$9.2 daily, including all investigations, medication, operation and meals

Private 5%

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Medical Education

2 Universities, basically British systemChinese University of Hong KongUniversity of Hong Kong5-year undergraduate study1-year internship of four 3-month rotations

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EM specialty status

1st Casualty Unit established in Queen Mary Hospital in 1947Early years, staffed by junior doctors, fresh graduates while waiting for training in other branch of medicineOne senior medical officer in-charge

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Birth of the Specialty

Formation of the Hong Kong Society of Emergency Medicine in 1985Mini-journal (Emergi-News) in 1990 and maturation into Hong Kong Journal of Emergency Medicine in 1994Establishment of Accident and Emergency Training Centre in Tang Shiu Kin Hospital in 1994

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Birth of the Specialty

Incorporation of the Hong Kong College of Emergency Medicine (HKCEM) in 1996 and admitted as a constituent college of Hong Kong Academy of Medicine (HKAM) in 1997

(HKAM was inaugurated in 1993, marked a new era in specialist training in Hong Kong)

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Hong Kong College of Emergency Medicine

Specialist training programme of 6 years including :Clinical experienceEmergency medicine Internal Medicine and subspecialtyGeneral Surgery and subspecialtyOther specialties

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Hong Kong College of Emergency Medicine

Specialist training programme of 6 years including :Other training requirement (Logbook)Cluster tutorialCase report / best evidence topics Joint Clinical Meeting / Toxicology

Round / Scientific MeetingClinical Skills Workshops

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Hong Kong College of Emergency Medicine

1st conjoint (intermediate) fellowship/membership examination with Edinburgh College in 19971st local exit examination in 1999 (with invited overseas examiners)Nominated for college fellowship after exit examination and fulfillment of training requirement

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EM specialty status

2003: 14 training centres with full time staffChanging staffing compositionConsultant(s) and Chief-of-Service with Senior Medical Officers (SMO) and Medical Officers (MO)Specialists (Consultants, SMO, MO)

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Academic Units

Honorary teaching staff appointed by 2 Universities since 1991, but no independent department1995, Professor appointed in Emergency Medicine Academic Unit, Chinese University of Hong Kong

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Pre-hospital Care

Government run Ambulance Service under Fire Service DepartmentFree serviceDispatch by Central control, staffed by senior fire officersChanging from simple first aid providers to Emergency Medical Technicians (EMA) with different levels since early 1990s

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Pre-hospital Care

Special skills of EMA IIIV lines and simple drugs by protocols Salbutamol nebulisation (puff) for asthma

and COPD IVI Dextrose for hypoglycaemia IMI Naloxone for narcotic overdose

Target for one EMA II on board of each ambulance in 2004

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Pre-hospital Care

Advanced EMA II+ (with advanced airway management with special adjuncts, Combitube, Laryngeal Mask Airway)Not up to Paramedic level (no endotracheal intubation, No ACLS)

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Pre-hospital Care

1st (part-time) Medical Director appointed in 1999Currently 2 part-time Medical DirectorsMoving towards EMA II+ and paramedic levelTo implement Trauma Diversion in Nov 03Consider different levels dispatch in future

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Current EM specialty status

14 training centres120 specialists, 200 trainees2 part-time Medical Director (Ambulance Service)

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EM System

In-hospital emergency care Front door (gate) of hospital service Self referral by patients Secondary and tertiary referrals No closure even if “no beds” in hospital Multi-specialty model with no differentiation

among AED staff Full admission right, except one (teaching

hospital) Follow up Clinic Recent enhancement in Observation

Medicine

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EM System

In-hospital emergency care Various degree of cooperation with

other specialties with agreed guidelines (Trauma team, ICU care)

Urgent consultation available to subspecialties – on call team or to specialist clinics

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Challenges and Strategies

Heavy patient loadTotal attendance 2.5M in 2001/2PYNEH – 10 specialists with 19

trainees to attend 500 daily attendance

Slight decrease with A&E chargingMajor decrease after SARS in Mar-Apr

2003

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Challenges and Strategies

Limited training opportunities Resources - Manpower issue Separate budget for each department No replacement for elective training,

“supernumerary staff” for elective training in physician training

Limited access to other “non-major” but essential specialties (Paed, O&T, ICU, O&G) >>>>> delay in maturation of EM training

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Challenges and Strategies

How are you trying to overcome these challenges?“Friends” with other “chief of service”Take chance of “mutual need”Recent support from Hospital Authority

– administrative means to decrease hospital admission >>>> Observation Medicine and access to supportive service

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Summary

Emergency Medicine specialty in Hong Kong at “paediatric” stage developmentDifficulties from heavy workload, limited resources for training and cooperation from other specialtiesGetting more support from administration because of efficient “gate keeper” role to decrease hospital admission