Emergency Medical Services in China: A Review of the Literature

Bositanguli. Keremu MSc, RN

Abstract

Background: Emergency medical service (EMS) is designed to provide

emergency care and transport critically ill or injured patients to the hospital. In
line with rapid urbanizations and economic growth, China’ enormous health care
system is facing significant challenges to protect their citizens from the growing
number of health emergencies caused by natural or man – made disasters.

Aims: The paper aims to identify and describe the comprehensive overview of
EMS systems in China.

Method: A literature search was conducted to identify the journal articles that
outline the Chinese EMS components using EBSCO Academic Search Premier,
PubMed and ProQuest Health databases from 1999 to 2015, and keywords EMS
system or emergency medicine or pre – hospital emergency services and China
were used. Abstracts were read and 6 relevant articles were selected for the
review.

Key issues: China EMS system development is unbalanced with great difference
throughout nations. There are no national or regional standard guidelines for pre-
hospital emergency services. In the absence of guidelines, the pre-hospital care
(PHC) systems are varied considerably across China and there is no “one – size –
fit – all” system for the entire PHC development. There is also no officially
recognized paramedic profession for emergency services.

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Implications for the future development: Government support of EMS is
needed to increase numbers of qualified paramedic professions across the country
and to develop pre – hospital emergency services in the rural areas. Continued
progress and expanded efforts should be made to improve ambulance response
time, coordination and public awareness regarding good emergency pre – hospital
care system through campaign in mass media.

Keywords: EMS system; Emergency medicine; Pre – hospital emergency

services; China

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Background

The People’s Republic of China is the world largest developing country with
a population of 1,3397 billion in 2010 (Peng, 2011). To date, there are only 1.5
million licensed physicians are available in China that density of physician is
about 1.42 for per 1,000 people (Du, 2014). In addition to shortage of emergency
healthcare staff, rapid urban and economic growth, along with aging population,
China’ enormous health care system is facing significant challenges to protect
their citizens from the growing numbers of health emergencies caused by natural
or man – made disasters (Man et al, 2012). Based on this background information,
the purpose of this literature review is to identify the components of Chinese EMS
system and discuss the strength and weakness of the current EMS system.

Overview of the EMS System in China

Since early 1980, the China Ministry of Health (MOH) has been taken steps
to establish an extensive network of emergency medical services throughout the
country. Despite this, most of rural populations are still unable access to the
emergency services from their residence (Thomas & Clem, 1999; Hung et al,
2009).

China EMS system has been driven and lead by MOH and Chinese
Association for Emergency Medicine. It has a top – down administrative principle
from the ministry to provincial and city bureaus (Thomas & Clem, 1999). The
Chinese EMS system is mainly categorized into three parts such as pre – hospital
emergency services, emergency departments (EDs) and emergency intensive care
units (EICUs). Pre – hospital emergency services include PHC and ambulance
services. This pre – hospital emergency system largely founded by provincial and
city bureaus of Public Health. However, patients are often required to pay for
ambulance and emergency treatment from their pocket (Hung et al, 2009).

Communication and dispatch system

Access of pre – hospital emergency services are accomplished by dialing

“120”. Using universal number of “120” for all types of medical emergencies

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make it easier for public to access EMS as they don’t need to remember several
numbers in emergency situation. However, the system does not have a formal way
of implementation and is not available in most of the rural areas of the country
(Hung et al, 2009). In general term, “120” call goes to the regional call center and
then ambulance request is forward to the closet and the appropriate dispatch center
in the area (See figure 1). In some areas, tertiary hospitals have their own pre –
hospital ambulance services and dispatch centers, as well as emergency call
numbers (Pei & Xiao, 2011).

Other public services such as fire and rescue services are achieved by
dialing “119” and police at “110”. The police and firefighter are not legally bound
to provide medical care mainly for rapid transportation with bare minimum first
aid provision (Hung et al, 2009; Pei & Xiao, 2011).

120
“120” calls goes to the regional call center

Regional Dispatch Center

Ambulance request is forward to the closet

and appropriate dispatch center in the area.

Ambulance Dispatch Center

Figure 1: Dispatch process flow – sheet in China

Pre – hospital care providers

In China, there is no officially recognized paramedic profession. Instead,

physicians, nurses and ambulance drivers provide pre – hospital emergency
services. Physician is responsible for overall management of critically ill patients
and nurses coordinate patient care. The staffs that are involved in PHC have
different knowledge, skills and competency. There is often shortage of staff in

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Chinese pre – hospital emergency system that doctors and nurses are not required
to have specialist training in pre – hospital emergency care (Hung et al, 2009; Pei
& Xiao, 2011; Gui et al, 2012). This can result in inconsistency of care, non
adherence to standard management protocol and inter-facility transfer policy.

There have three tiers in Chinese PHC providers. First tier as a first
responder includes basic first aider (e.g. layperson) and advanced first aider (e.g.
firefighter or police). Second tier is associated with basic PHC providers for
example nurse. Third tier include advanced PHC providers such as doctors and
trained emergency staff (Hung et al, 2009).

Types of pre – hospital care models

The main purpose of the pre – hospital care is to decrease morbidity and
mortality in those severely injured or in critically ill patients outside of hospital. It
is about 39% to 47% of pre-hospital deaths are preventable (Lockey, 2001).

As most of the people are shifting out to urban areas, this in turn, leads to a
higher crime rate, more accident cases of motor vehicle and other traumatic
injuries, and thus a greater need for pre-hospital care. However, PHC systems in
China are numerous due to varied socio – cultural, economical and geographical
differences in different parts of country. There is no “one – size – fit – all “system
for the entire pre – hospital care development. There are following five different
systems that exist in major cities of China (Man et al, 2012; Hung et al, 2009).

• Independent emergency service center

In Beijing and Shenyang, pre – hospital emergency services are independent

to hospital EDs. They have their own EDs and EICUs. The centers are well
equipped with their own operating room, ICUs, radiology, hyperbaric chamber
and blood bank. The Beijing emergency center radius is about 3 to 5 km with
response time between 5 to 10 minutes.

• Pre-hospital emergency service supported by a general hospital

In Chongqing, Chengdu, Qingdao and Haikou, PHC are provided by

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nearby hospitals with integration of both pre and in hospital emergency care. The
ambulance is staffed by the healthcare provider from the hospitals. This model
potentially increases workload of the emergency staff while decrease the
efficiency of ED.

• Purely pre-hospital care

In Shanghai, Tianjin, Nanjing, Wuhan and Hangzhou, pre – hospital

emergency centers are without inpatient beds. In Shanghai, there are 17 PHC
station are available in urban areas and 11 are dispatched around the districts. A
network of urban service radius is about 4.5 km with response interval 10 minutes.

• Unified communication command center

In Guangzhou and Shenzhen, there is no PHC service center for ambulance

dispatch, but with unified with communication command center for dealing with
“120” emergency call in the area. After receiving the call, regional center will
forward it to the nearest appropriate hospital for ambulance dispatch. This system
can possibly shorten the response time and improve chances of survival among
critically ill patients.

Integrated with fire and police department

In Suzhou and Hong Kong, the PHC service is combined with the fire and
police departments.

Training

There is no standardized certification for pre – hospital care providers within

China. PHC providers that staffing the ambulances have formal training in
medical care, but not necessarily trained in PHC.

To date, there is no specific national paramedic-training institute. Although

few private institutions have started their own paramedic training programs, but
their curriculum is not the standardized curriculum. Moreover, the driver of the
ambulance has no formal medical training and neither is he/she a specially trained
to handle ambulances or EMS vehicles (Man et al, 2012; Hung et al, 2009).

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Transportation and Facilities

The goal of transportation is to bring the right patients, via right transport
mode, to the right center within the right time. According to recent studies,
traumatic injury, coronary heart disease (CHD) and cerebrovascular disease
(CVD) are the most frequent reasons for calling ambulance services in China
(Hung et al, 2009; Man et al, 2012; Guo et al, 2008; Gui et al, 2012). However,
land ambulance still remains the main transport mode of pre – hospital emergency
services in China. Air ambulance is rarely available for public use except for only
national disaster case. Generally, there are two types of land ambulances are used
in China such as type A and B. Type A is an advanced monitoring ambulance
equipped with intensive care facilities such as transport ventilator, defibrillator,
cardiac monitor and a wide range of medication for resuscitation of critically ill
patients. However, this type of ambulance is only available in major cities.
Whereas, type B is the general ambulance equipped with basic equipment for
example, trauma kit, immobilization and splints for suspected fractures. This type
of general ambulance is widely available in district hospital and some rural health
centers. Moreover, in China, ambulances often use two-way radio
communications and global positioning system (GPS) to urge response time
(Hung et al, 2009).

Pre – hospital care for patients with trauma

Traumatic injury due to traffic accident is the single most common cause
responded to by ambulance service in China (Liu et al, 2004; Man et al, 2012;
Guo et al, 2008; Gui et al, 2012). Road injuries are responsible for 700,000 deaths
and more than 62 million ED visits annually nationwide (Du, 2014). According to
data from the Shanghai and Shenzhen EMS centers, road injury causes almost
47% of ambulance call in Shenzhen by 2011 and similar situation in Shanghai,
accounting for 36.7% of emergency call during 2003 to 2007 (Man et al, 2012;
Gui et al, 2012).

The pre – hospital care of traumatic injured patients is based on timely and
appropriate intervention through each stage of trauma chain of survival, which
including, early first aid, early BLS or ALS, early advanced therapy and early
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rehabilitation (Søreide, 2012). However, to date there are no national guidelines
set up for triage, patient-delivery decision, pre-hospital treatment, and transfer
protocols. In the absence of guidelines, there is no officially recognized advanced
trauma life support (ATLS) paramedic profession in China. The physician and
nurses are under the operation of pre – hospital trauma care. Most of the regions
have hybrid advanced trauma life support or basic trauma life support (BTLS)
services (Du, 2014).

In addition, formal training or education is not compulsory for healthcare

staff involved in pre – hospital trauma care. Decisions about choice of the
destination hospital is made on an individual basis. Although international trauma
life support (ITLS) training is introduced to China in 2011, but this is widely
accepted only in major cities (Du, 2014). As a results, absence of standard
guideline and educational training for pre – hospital care providers bring in
unskilled labor to deal with those massive numbers of trauma cases.

Pre – hospital intervention for patients with adverse cardiac event

As people are living longer, disease pattern has been changed over the year,
and this results in an increase of the number of cardiac - related diseases among
population. The mortality rate for sudden cardiac death (SCD) increased
dramatically, to 44.6 of 100,000 per year for men and 39.0 of 100,000 per year for
women (Hua et al, 2009). According to Shanghai EMS center, cardiovascular –
related emergency causes about 24% of ambulance call between 2003 to 2007
(Gui et al, 2012). The chance of survival in these coronary heart diseases is often
influenced by time-dependent interventions. A patient with the acute myocardial
infarction for example, requires initiation of early thrombolytic treatment through
the “door – to needle” time less than 30 minutes. However, in reality, the mean
“door to needle” time indicated in a recent study in China was about 120 minutes
(He et al, 2004; Cheng et al, 2007).

The chance of cardiac arrest survival depends on early initiation of

cardiopulmonary resuscitation (CPR). But unfortunately, there is no universal
target time for pre – hospital arrival in China (Hung et al, 2009). According to

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Guo et al, (2008) the ambulance response time ranges from 15 minutes to 30
minutes, depend on location (i.e. rural area) and traffic jam. Hence, public plays a
key role in providing bystander CPR before the arrival of ambulance. However, to
date aspects of bystander CPR performance in China have not been studied yet.

Therefore, improvement of ambulance response time and health promotion

strategies to improve community awareness regarding early signs of cardiac arrest
and educate them regarding CPR to initiate early intervention by first responders
are pivotal to improve cardiac arrest survival for cardiac victims.

Implications for the future development:

Although pre – hospital care service in China has improved significantly,

there is still much room for further improvement.

• Improve ambulance response time and wider availability of air ambulance

services throughout the country.
• Improve availability of EMS in rural areas
• Develop paramedic status.
• Develop health promotion strategies to improve public awareness
regarding good emergency pre – hospital care system through campaign in
mass media (e.g. know when and how to access the emergency system
rapidly)
• Encourage public, not just to know, but also to be ready and willing to
contribute and give first aid care (e.g. bystander CPR).
• Assure coordination of EMS system through effective partnerships.
• Assure adequate financing

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