1. 1 TRACK E Status of Emergency Medicine Around the World - Hong Kong Dr. LAU Chor-chiu Consultant and Chief-of-Service Pamela Youde Nethersole Eastern Hospital Hong Kong

2. 2 Hong Kong (Special Administrative Region) Population 6.787 million Area 1,102 square Km

3. 3 Hong Kong (Special Administrative Region) Location Southern part of Guangdong Province History British Colony from 1842, returned back to China on 1 Jul 1997

4. 4 Hong Kong (Special Administrative Region) International city predominantly Chinese descent (95%), Cantonese speaking 2001 Census Population 6.7M Sex ratio (M/F) 0.956 : 1 Age 0-14 : 16% Age 15-64 : 72% Age > 65 : 11% (Census and Statistics Department, HK)

5. 5 Hong Kong Population Age Pyramid

6. 6 Hong Kong (Special Administrative Region) Socio-economics Estimated GDP (2002) Eu$146,101m Estimated total public spending on health care (2001/02) about 2.7% GDP

7. 7 Age specific Mortality Rates by Disease Groups 2001 (All age) Neoplasm172.8 Diseases of circulatory system125.6 Disease of respiratory system82.3 External causes of morbidity and mortality27.4 Diseases of genitourinary system21.5 Disease of digestive system19.3 Certain infections and parasitic diseases13.8 Endocrine, nutritional and metabolic diseases11.5 Diseases of nervous system4.6 Signs, symptoms & abnormal clinical and laboratory findings, not classified elsewhere 4.5

8. 8 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%

9. 9 Medical Education 2 Universities, basically British system Chinese University of Hong Kong University of Hong Kong 5-year undergraduate study 1-year internship of four 3-month rotations

10. 10 EM specialty status 1st Casualty Unit established in Queen Mary Hospital in 1947 Early years, staffed by junior doctors, fresh graduates while waiting for training in other branch of medicine One senior medical officer in-charge

11. 11 Birth of the Specialty Formation of the Hong Kong Society of Emergency Medicine in 1985 Mini-journal (Emergi-News) in 1990 and maturation into Hong Kong Journal of Emergency Medicine in 1994 Establishment of Accident and Emergency Training Centre in Tang Shiu Kin Hospital in 1994

12. 12 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)

13. 13 Hong Kong College of Emergency Medicine Specialist training programme of 6 years including : Clinical experience Emergency medicine Internal Medicine and subspecialty General Surgery and subspecialty Other specialties

14. 14 Hong Kong College of Emergency Medicine Specialist training programme of 6 years including : Other training requirement (Logbook) Cluster tutorial Case report / best evidence topics Joint Clinical Meeting / Toxicology Round / Scientific Meeting Clinical Skills Workshops

15. 15 Hong Kong College of Emergency Medicine 1st conjoint (intermediate) fellowship/membership examination with Edinburgh College in 1997 1st local exit examination in 1999 (with invited overseas examiners) Nominated for college fellowship after exit examination and fulfillment of training requirement

16. 16 EM specialty status 2003: 14 training centres with full time staff Changing staffing composition Consultant(s) and Chief-of-Service with Senior Medical Officers (SMO) and Medical Officers (MO) Specialists (Consultants, SMO, MO)

17. 17 Academic Units Honorary teaching staff appointed by 2 Universities since 1991, but no independent department 1995, Professor appointed in Emergency Medicine Academic Unit, Chinese University of Hong Kong

18. 18 Pre-hospital Care Government run Ambulance Service under Fire Service Department Free service Dispatch by Central control, staffed by senior fire officers Changing from simple first aid providers to Emergency Medical Technicians (EMA) with different levels since early 1990s

19. 19 Pre-hospital Care Special skills of EMA II IV 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

20. 20 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)

21. 21 Pre-hospital Care 1st (part-time) Medical Director appointed in 1999 Currently 2 part-time Medical Directors Moving towards EMA II+ and paramedic level To implement Trauma Diversion in Nov 03 Consider different levels dispatch in future

22. 22 Current EM specialty status 14 training centres 120 specialists, 200 trainees 2 part-time Medical Director (Ambulance Service)

23. 23 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

24. 24 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

25. 25 Challenges and Strategies Heavy patient load Total attendance 2.5M in 2001/2 PYNEH – 10 specialists with 19 trainees to attend 500 daily attendance Slight decrease with A&E charging Major decrease after SARS in Mar-Apr 2003

26. 26 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

27. 27 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

28. 28 Summary Emergency Medicine specialty in Hong Kong at “paediatric” stage development Difficulties from heavy workload, limited resources for training and cooperation from other specialties Getting more support from administration because of efficient “gate keeper” role to decrease hospital admission