Critical challenges in establishing emergency physician driven emergency departments – A Durban experience

Abstract

Emergency medicine (EM) has become a global discipline and plays an integral role in providing integrated emergency medical care. In South Africa, emergency medicine is a relatively new discipline, and while well-established in the Western Cape and Gauteng, it is still in its infancy in KwaZulu-Natal. Although training in EM has been on-going at the Pietermaritzburg and Ngwelezane complexes, there are currently no accredited training facilities in the Durban Metro area, and only two emergency physician-headed Emergency Departments (EDs) in the eThekwini region. Despite understanding the unique complexities of the KwaZulu-Natal health system, we still encountered numerous challenges in establishing functional emergency physician driven EDs in Durban. Challenges encountered were: • Lack of awareness of the existence of emergency medicine as a specialty. • Lack of interaction between emergency departments and other disciplines. • Inadequate staffing of the ED: the ED is still seen as a refuge for those who have nowhere else to work, and has not been a staffing priority for most facilities. • Poorly equipped, under-resourced emergency departments. • No evidence based practice guidelines and undefined inter-facility referral policies. • ED overcrowding and access block. Strategies reviewed to integrate Emergency Medicine in Durban hospitals: • Marketing Emergency Medicine – creating awareness of the function and goals of Emergency Medicine in delivering emergency medical care. • Breaking tradition – transform all ”casualties” into ”Emergency Departments”. Reaffirming to local hospital and Department of Health policy makers that emergency medical care should be performed by the provider who can most efficiently perform the task (where ’efficiency’ balances quality of care, cost and patient flow). • Coordinated patient care, early intervention and referral, and team work between different disciplines. • Using Emergency Medicine models and systems established in other regions as motivation for implementing Emergency Physician run EDs locally. What has been done so far? • Establishment of a Division of Emergency Medicine at the University of KwaZulu-Natal. • Canvassing of policy makers to establish ongoing postgraduate training in Emergency Medicine in the Durban Metro area has commenced. • Ongoing interaction with the Department of Health and the Provincial Health managers to establish norms and standards for emergency care in the region • Active recruitment of specialist emergency physicians to augment clinical structures and improve the training for registrars. The Western Cape experience has demonstrated the utility of an Emergency Physician led Emergency Department in improving the outcome of acute illness and trauma, which are strongly dependent on the early recognition of severity and the need for early intervention. We believe that a similar mind-set needs to be developed to service the increasing needs of the urban and peri-urban population served by eThekwini hospitals.