Remember me
ORIGINAL ARTICLE
Year : 2021 | Volume
: 10
| Issue : 3 | Page : 202-210
Emergency medical response services in the union territory of Dadra and Nagar Haveli, India
Vikram Khan1, Ankush A Sanghai1, Dolatsinh B Zala2, VK Das1
1 Directorate of Medical and Health Services, UT of Dadra & Nagar Haveli and Daman & Diu, India
2 Department of Microbiology, NAMO Medical College, Silvassa, UT of Dadra & Nagar Haveli and Daman & Diu, India
Correspondence Address:
Dr. Vikram Khan
Directorate of Medical and Health Services, UT of Dadra and Nagar Haveli and Daman and Diu, Silvassa - 396 230
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijhas.IJHAS_194_20
BACKGROUND: Emergency medical response services (EMRS) are an integral part of today's health system. Prehospital care and transport of a patient to the health facility is the main function of EMRS. It is very difficult to evaluate the efficacy of this system. The evaluation of the efficacy of the EARS based on various parameters is the main aspect of the study. In this observational study, the epidemiology of emergency, utilization of services, quality and cost matrixes of services were analyzed.
MATERIALS AND METHODS: The study was conducted in Union Territory of Dadra and Nagar Haveli, India from January 1, to December 31, 2017. The secondary data were collected from the Emergency Response Centre. Various parameters such as epidemiology of medical emergencies, extent pattern of utilization of EMRS, quality of services, and cost parameters were recorded.
RESULTS: Total 28716 medical emergencies were handled by EMRS in the year 2017. Among them acute abdominal pain was recorded as the most common emergency, followed by pregnancy-related emergencies and fever. Most of the users belonged to the rural/tribal area and females utilized the facility more than males. The average response time for providing the services in the rural and urban area was recorded as 8:42 min and 13:25 min, respectively. Various parameters of service utilization, cost-effectiveness, and quality were noted.
CONCLUSIONS: The planning and support from all levels (at the national, provincial and community) are important aspect to provide quality and cost-effective services. The data of EMRS may help to develop quality benchmark for the EMRS.
Keywords: Ambulance, data mining, emergency medical response services, operations research
Emergency medical response services (EMRS) system, on the other hand, refers to a mechanism for accessing and reporting an emergency; prehospital service delivery; transport mechanisms; definitive, speciality, and rehabilitative care facilities; public education; participation and prevention processes; resource allocation and financing structures; and coordinating the role of collaborating organizations.[1] The main purpose of EMRS is to provide 24 × 7 services to meet the emergency services demands of the population in the necessary quantity and quality. The various researchers have attempted to analyze the elements of EMRS like as the response time of service,[2],[3] misuse of services,[4],[5] gap and challenges in service,[6],[7] epidemiological aspect of emergency,[8],[9] and implementation or development of service.[10],[11],[12],[13],[14] In the Indian scenario, the EMRS have been institutionalized as a public-private partnership at the state level which caters their services through three digits numbers 108 and 102.[15] Selected studies have analyzed the impact of EMRS on the indicators of the maternal and child health.[16],[17],[18],[19],[20] However, various demand-side and supply-side interventions have been initiated in India to improve the access of EMRS to public sector health facilities for both the poor and rich, and those living in hard to reach areas.[14],[21],[22] Therefore, in the present investigation, we evaluated the various indicators of EMRS such as performance, utilization, quality, cost-effectiveness, and epidemiology of emergency handled by EMRS along with sociodemographic correlates.
Materials and MethodsStudy setting
The Union Territory of Dadra and Nagar Haveli (UT of D and NH) is situated on the western coast of India between the states of Gujarat and Maharashtra. It lies between north latitudes 20° 02' and 20° 22' and east longitudes 72° 54' and 73° 14'. The UT of D and NH is spread over an area of 491 km2 which comprises 72 villages and a single district. The headquarters UT of D and NH is located at Silvassa. EMRS was launched in the UT of D and NH on 10 April 2012 under a public-private partnership with public financing and private delivery. The call center of the private provider was established in Shri Vinoba Bhave Civil Hospital, Silvassa. The EMRS works through 24 × 7 × 365 centralized Emergency Response Centre (ERC). The ERC is currently staffed with 15 Emergency Response Officers (EROs), 1 Team Leader (TL), 1 Human Resource Manager, 2 ERC Physician, and 1 Programme Manager. The ambulances are staffed with Pilot (Trained Driver) and Emergency Medical Technician (Paramedical Staff). The ambulances could be called to the place of emergency by dialing a toll-free number '108' throughout the UT. Nearest ambulance available to the site is dispatched by ERC by using a well-functioning Geographic Information System [Figure 1]. The function of the ERC is given in [Figure 2].
Figure 1: Geographic Information System map showing strategic location of ambulance in the Union Territory of Dadra and Nagar HaveliData set
The secondary data of medical emergencies were drawn from the EMRSs tracking software which is generated from the calls received at the centralized call-centre for availing EMRSs. The ERO is responsible for call handling and live entry of data in the EMRSs tracking software. The TL and the manager are responsible for the purity of data at the ERC. The assessment question related to the epidemiology of medical emergencies, utilization pattern of services, quality of services, and cost-effective were analyzed.
The details of the methodology, assessment question and parameters, analyzed in the present study are summarized in [Table 1]. The time taken for emergency services days were divided into three 8-h intervals, that is, night period as 00:00–08:00, day period as 08:00–16:00, and evening period as 16:00–24:00. The year was divided into three seasons such as summer (March to June), rainy season (July to October), and winter (November to February). The software SPSS was used for data analysis.
Table 1: The overview of the methodology for evaluation of emergency response services in the union territory of Dadra and Nagar Haveli, India Results A total of 1, 15, 874 medical emergencies were reported during the last 6-year (7525 emergencies in 2012, 14,343 emergencies in 2013 17,715 emergencies in 2014, 22,269 emergencies in 2015, 25,306 emergencies in 2016, and 28,716 emergencies in 2017).
Stratification of emergencies by health institutions
In the year 2017, 48.78% emergencies were handled by tertiary care hospital followed by 36.73% in secondary care sub-district hospital, 2.87% in secondary community health centers, 10.78% in primary health centers, 0.36% other nearest Government Hospitals, and 0.48% private/trust hospitals.
Stratification of emergencies by geographical locations
Among the total medical emergencies, 56.39% of medical emergencies were handled by the ambulance of the rural location, 25.28% emergencies were handled by the ambulance of semi-urban/industrial location and 18.32% were handled by the ambulance of urban location [Table 2]. These numbers were also compared with the percentage of the population seen in these areas. Based on the prevalence of emergencies, a mapping of the state was carried out in [Figure 3], with red depicting “low prevalence,” blue “high” and yellow “moderate “prevalence. The location-wise utilization pattern of EMRSs is given in [Table 2].
Table 2: Location-wise utilization pattern of 108 emergency medical responce services in year 2017
Figure 3: Showing the village wise incidence of medical emergencies in year 2017Epidemiology of medical emergencies
Average 78.67 emergencies per day were handled by EMRS during the year 2017. Total number of emergencies per lakh (1 million = 10 lakh) population per day were reported as 17.54. The most common emergencies to be reported were acute abdomen, pregnancy-related, fevers (infections), trauma (vehicular), trauma (nonvehicular), animal bites, respiratory related, cardiac/cardio vascular, assault, and poisoning/drug overdose. These values are compared with the differences in gender and age [Table 3].
Table 3: The types of emergencies handled by 108 emergency medical response services in the year 2017Acute abdomen
Among the emergencies, the acute abdomen is the most common emergency. A total of 5983 cases were reported in the year 2017. This was 20.84% of total emergencies. Among the acute abdomen cases, 3125 (52.23%) females and 2852 (47.67%) males with an average age of 30.21 years and 29.69 years, respectively. The highest number of cases were encountered between the age group of 19–30 years (39.26%) followed by 31–50 years (28.39%).
Pregnancies related emergencies
A total of 5827 pregnancy-related emergencies were attended by the “ERC during the study period. The proportion of pregnancy-related emergencies handled by “108” was 20.29% of total emergencies. The Ambulances were assigned almost 100% for managing pregnancy-related emergencies. The proportion that did not use an ambulance (despite being assigned) was reported at 0.05%. About 93.35% of pregnancy-related emergencies were attended by 108 services within 30 min of the time [Figure 4].
Figure 4: Showing a timeline of pregnancy-related emergencies (from location to seen) during 2017Fever
Fever is the third-most regular health emergency handled by EMRSs. Out of total emergencies, 17.36% (4986) were fever cases. Most of them were reported in young age group, i.e., between 19–30 years (31.35%) and children <5 years of age (20.82%). With respect to gender, (male: female) ratio for fever-related emergencies was 1.25:1.
Trauma and assault
A total of 3425 cases of trauma (2067 cases of vehicular trauma and 1358 nonvehicular trauma) were handled by 108 services during the study period. The vehicular trauma was more commonly observed in male (81.66%); below the age group of 19–30 years (48.72%). The nonvehicular trauma was also reported more in male (70.32%) in the age group of 19–30 years (30.49%). During the period of study, total 399 cases of assaults were encountered, the majority of victims were male (71.68%), belonging to the age group of 31–50 years (45.61%). The mean age of people who have encountered trauma and assault was male 35.12 years and female 37.33 years.
Animal bite
A total of 776 victims of animal bites (418 cases of snakebite, 55 cases of the Dog bite, 15 cases of Scorpion bite, 9 cases of insect bite, 4 cases of wild animal bite, and 275 cases bites from unknown animals) were handled by EMRSs. Gender wise analysis of animal bite victims shows that the male-female ratio of 1:1.3 with a mean age of 31.68 years and 29.81 years, respectively. The maximum numbers of animal bite victims were between the age group of 19–30 years (29.77%) followed by 31–50 years (28.48%) and 6–18 years (22.81%). Based on seasonal variation, it was observed that 46.12% of animal bites emergencies were reported during the monsoon season.
Respiratory
Total of 760 cases of respiratory-related emergencies was handled by EMRSs in the year 2017. The gender-wise analysis states that out of all total cases 53.82% happened in males and 46.18% were in females. The highest numbers of respiratory emergencies were reported in a 50 plus age group (28.55%), followed by 31–50 year age group (27.24%) and 19–30 year age group (20.39%).
Cardiovascular emergencies
A total of 594 cardiovascular emergencies cases were attended by 108 services during the study period with an average of 1.62 emergencies per day. During the second section (July to September) more cardiovascular emergencies (2.10 emergencies per day) were reported. Most of the cardiovascular emergencies have occurred in males (60.10%), with 1.5:1 male:female ratio. The cardiac emergencies were the highest in the age groups of 31–50 years (37.21%) and >50 years (27.61%), with a mean age of 40.59 years.
Time of emergencies
It was found that 25.79% of emergences were reported during the night period (00:00–8:00 h), 32.78% of emergencies were reported during the day periods (08:00–16:00 h) and 41.43% of emergencies were reported in the evening period (16:00–24:00 h). The peak hours of emergencies were from 9:00 to 11:00 in the day, from 8:00 to 10:00 pm. period and in the night it was between 00:00 and 2:00 h.
Seasonality of emergencies
It was observed that acute abdomen and fever cases were increased during the rainy season and decreased in summer and winter season. The animal bite emergencies which increased from late summer remained high throughout the rainy season up to first part of winter. The trauma cases both vehicular and nonvehicular remained steady throughout the year and did not increase sharply in the particular season [Figure 5].
Figure 5: Showing seasonal variation in different types of emergencies handled by emergency medical response services in the year 2017Utilization of emergency medical response services
The estimated density of ambulance was 24/1000 km2. The average number of patients transported per ambulance per day was 4.6 (range 0.7–8.8). The mean number of distance recorded per ambulance per day was 104.6 km (range 31.73–198.59 km) and the mean distance of per emergency was calculated 21.36 km (range 6.91–35.37 km). Based on gender, more females have utilized 108 services than males.
Quality of services
A total of 28,716 effective calls were received at ERC during the year 2017. The mean number of effective calls per ambulance was recorded as 4.61. The EROs took an average time of <2 s to answer a call and the average call handling time for rural 2:09 min and in urban 2:10 min. In the present investigation, the average response time of ambulance from base to site was reported as 8:42 min in urban and 13:25 min in rural areas, from the site to the hospital, 4:27 min in urban and 16:28 in rural areas. The complete cycle time of ambulance per case was 57:21 min in rural and 25:30 min in urban (from a call received to back to the base). The emergency-wise response time was calculated and given in [Table 3]. The utilization rate of ambulances in the UT of D and NH was 99.99% in 2017. No incident of major accidents and workforce shortage was reported. The average number of trips taken by an ambulance per day was recorded as 4.62 trips.
Cost of operating the ambulance services
The Administration of UT of D and NH is operating the EMRSs and 104 citizen helpline. The total cost for the services per month per ambulance in the year 2017 was 1.44 lakh, the average cost per emergency is 1027.91 Rupees and the average cost per kilometers is 51.49 Rupees.
DiscussionThe EMRSs can make an important contribution to reducing avoidable death and disability but it needs to be planned well and supported at all levels-at the national, provincial and community. It is a major strategy for improving the indicators of India's flagship program.[7],[23] In the present scenario, the maximum emergencies were handled by tertiary care hospital and secondary care sub-district hospital; it may be possibly the maximum number of facilities and specialties are available in the tertiary care and secondary care hospitals. It's no surprise; therefore, that attracts all kinds of emergencies from all places in the UT. The other causes of high emergency load in tertiary care hospital may be the proximity of the hospital to the scene of the emergency, the perception in the community that the management at tertiary care and secondary care hospital is better than other hospitals. Among the total medical emergencies, >50% of medical emergencies were handled by the ambulance of the rural location. Its maybe due to the availability of limited recourses of transportation in rural areas and faith of community on EMRS. Use was more prevalent among the poor, and lower social and economic sections of the population.
The common emergencies in the UT of D and NH are acute abdominal pain followed pregnancy-related emergencies, fever, trauma both vehicular and nonvehicular. However, the most common emergency is pregnancy in Goa and Assam.[8],[24] The higher proportion of acute abdomen and fever cases were seen in the productive age groups. The major causes of acute abdomen and fever are the unavailability of the safe sources of drinking water, hygienic food and lack of awareness of health hygiene practices. These calls for an urgent need to address prevention policies aimed at this productive age group. It was observed a higher proportion of pregnant women's are using the EMRS in the UT of Dadra Nagar Haveli. It is well documented that the approachable access of quality EMRS contributed significantly reduction in-home deliveries, infant mortality and maternal mortality. There is no doubt that EMRS have a significant role in improve the indicator of maternal and child health in the UT of Dadra Nagar Haveli.
It is well-known that pre-hospital care and shifting of person to nearest health facility reduces deaths as well as lifelong permanent disability in the person affected due to trauma.[25],[26],[27] In the present investigation, 11.91% of total emergencies were reported due to trauma (both vehicular and nonvehicular). The average response time of response services from location to the scene was reported as 11 min 37 s. Its up to the mark in comparison with the other countries such as 27 min in São Paulo, Brazil, 21 min Belo Horizonte, 17.87 min Tabriz, Iran.[28],[29],[30] However, as per the WHO, ideal response time is equivalent to >8 min in life-threatening emergencies.[28],[31]
The animal bites can be called as an occupational disease; it's mostly affecting farmers, plantation workers, herdsmen, hunters, or workers on the development sites. The present study depicts that out of total Animal bite cases 53.86% are snake bite emergency and all are transported to the nearest health facility by EMRS with an average response time of 11.37 min. Rapid transport of the snakebite victims to treatment center decreased the CFR from 10.5 % to 0.5%.[32] The incidence of the animal bites which increased from late summer remained high throughout the rainy season up to the first part of winter. The causes of the animal bites may be due to breeding seasons, flooding of the habitats or coming in contact with a human during the search of food. Farmers are more prone to accidental contact with animals, especially when they work in the fields.
The cardiac emergency is a leading factor, causing mortality around the world. The greater number of cardiac emergency was reported in the age group of 35–50 (32%) with mean age 49 years in male and 45 years in females from Andhra Pradesh, India.[33] The result of the present study confirmed that the most affected age group due to the cardiac emergency is 31–50 years. However, the mean ages of males are lesser in comparison to the previous study conducted in Andhra Pradesh, India. Only 2.60% of total emergency was reported due to respiratory-related emergencies in may be due to rapid expansion, development, industrialization and urbanization of the UT of D and NH. The associations between the emergency medical services response time and the risk of death in life-threatening emergencies have been established.[2],[3] EMS systems attempt to achieve a response and shock time of 8–10 min from collapse to provide the maximum potential for successful cardiac and cerebral resuscitation.[34]
A great variation in the average response time of emergency medical services was reported by previous workers. Only 5 min average response time of emergency medical services was in Taoyuan, Taiwan and Salt Lake City, USA and 28 min average response time of emergency medical services in Athens, Greece.[35],[36] WHO set the quality benchmarked of average response time is equivalent to <8 min in life threatening emergencies.[28] In the present investigation, the average response time of ambulance as 8:42 min in urban is good in comparison with the previous study. However, the response time of ambulance as 13:25 min in rural areas is slightly higher.
The present study shows an average of 4–5 patients being handled by ambulance per day. The utilization rate of the ambulance in this was found optimal from an efficiency viewpoint in comparison of earlier reports from Haryana and Punjab.[16],[23] Poor and those who are at a site away from the health facility have a higher likelihood of using the 108 services, reflecting equitable utilization. The results of study indicate that the cost of operating the ERS service using a private provider in the year 2017 is INR 1027 (USD 14.16) per patient transport or INR 51.50 (USD 0.71)/km travelled. It was higher as compared to Haryana (INR 548.93 in the year 2010) but it's lower in comparison of Punjab (NRI 1361 in the financial year 2013).[16],[18],[23] The average number of ambulances per million populations is 37.69 in the UT of D and NH, which is higher in comparison of other states like Andhra Pradesh, Gujarat, Karnataka, Punjab and Haryana.[37] The Mean number of patients handled per ambulance per day was 4.69 in the UT of D and NH is also quite high in comparison of Andhra Pradesh (3.59) and Punjab (3.50).
ConclusionsThe cause of its high utilization may be due to poor socioeconomic conditions of the area, free of cost availability of services, good response time (8:42 min in Urban and 13:25 min in Rural) awareness among the community, good quality of services and easy access to 108 ambulance services. The epidemiological data of the emergencies may be utilized as presumptive surveillance of communicable as well as noncommunicable disease and may help to identify unusual health events and suggest a timely intervention to prevent an outbreak.
Limitations
The secondary data from January 1, to December 31, 2017 were drawn from the software which is generated from the telephonic calls received at the centralized call-center for availing EMRSs. The disease conditions mentioned in the software were broadly described and not specific. Hence it was difficult to analyze the actual disease conditions. Furthermore, the epidemiological data suggested the pattern of emergency handled by EMRS only and not the actual emergency data, as non EMRS user emergency victim's data is not available.
Acknowledgements
The authors are grateful to the Administration of the UT of D&NH and DD for support in data collection.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
Comments (0)