PerspectivesPerspectives

Health systems and services: the role of acute care Jon Mark Hirshon,a Nicholas Risko,a Emilie JB Calvello,a Sarah Stewart de Ramirez,b Mayur Narayan,c Christian Theodosisa & Joseph O’Neilld for the Acute Care Research Collaborative at the University of Maryland Global Health Initiative

Introduction organize the inputs necessary for the Fragmented health system provision of effective interventions; As populations continue to grow and and services (ii) as inclusive of promotion, preven- age, there will be increasing demand for tion, cure, rehabilitation and palliation In 2007, WHO highlighted the need to acute curative services responsive to life- efforts, and (iii) as oriented towards strengthen health systems, but precise threatening emergencies, acute exacerba- either individuals or populations.1,2 definitions and objectives, especially tion of chronic illnesses and many routine Acute care must also be clearly with regard to the delivery of health health problems that nevertheless require defined. Standard medical definitions services, often remain elusive.4 Priority prompt action. Emergency interven- for acuity emphasize the singular at- health problems are on consensus lists tions and services should be integrated tribute of time pressure.3 Acute ser- that countries normally develop with with primary care and public health vices therefore include all promotive, input from international organizations. measures to complete and strengthen preventive, curative, rehabilitative or Health services are then oriented to- health systems. This paper focuses on palliative actions, whether oriented to- wards preventing and controlling these acute care within that context. First, we wards individuals or populations, whose priority health problems. One important draw on standard World Health Organi- primary purpose is to improve health component that has yet to be adequately zation (WHO) terminology to propose and whose effectiveness largely depends elucidated within these processes is the working terms to define “acute care”. on time-sensitive and, frequently, rapid influence of time on the implementation Second, we highlight the fragmentation intervention. and success of interventions. Preventive of service delivery that results from not Many individually-oriented ser- strategies primarily focus on reducing adopting the proposed definition. Third, vices have optimal delivery times. As the probability of incident cases through we show the potential contribution of a group, acute curative services are interventions that decrease the risk of acute care to integrated health systems the most time-sensitive, regardless developing a disease. The sooner preven- designed to reduce all-cause morbidity of disease entity. However, to date, tion efforts begin, the sooner incidence and mortality. Finally, we propose key acute care has been poorly defined falls. On the other hand, curative strate- steps to further the development of acute and inadequately supported in most gies reduce the probability of disability or care that leaders, researchers and health developing health systems. A reason- death among existing cases. The relative workers, who are the people responsible able working definition of acute care priority assigned to curative interven- for maintaining strong national health would include the most time-sensitive, tions is driven by how time-sensitive and systems, should consider taking. individually-oriented diagnostic and effective the interventions are, as well as Defining acute care curative actions whose primary pur- by cost. However, in the case of curative pose is to improve health. A proposed services, the relationship between time Clear definitions of health systems and definition of acute care includes the and effectiveness varies, which makes it services are required to create a com- health system components, or care de- important to get the patient to the right mon language to encourage discussion livery platforms, used to treat sudden, place at the right time for the right in- and help focus system development often unexpected, urgent or emergent tervention. Failure to consider the time efforts. Health systems include all or- episodes of injury and illness that can component of curative services produces ganizations, institutions and resources lead to death or disability without fragmentation through poor coordina- “whose primary purpose is to promote, rapid intervention. The term acute care tion of care and the imprecise application restore and/or maintain health”.1 Health encompasses a range of clinical health- of clinical interventions, such as delays in services are “aimed at contributing to care functions, including emergency treating sepsis with antibiotics leading to improved health or to the diagnosis, medicine, trauma care, pre-hospital death or disability. Fragmented care re- treatment and rehabilitation of sick emergency care, acute care surgery, duces the number of disability-adjusted people”, and they can be viewed from critical care, urgent care and short- life years (DALYs) that can be averted several perspectives: (i) as actions to term inpatient stabilization (Fig. 1). with a given set of resources.

a Department of Emergency Medicine, University of Maryland School of Medicine, 10 South Paca Street, Room 4S-127, Baltimore MD 21201, United States of America (USA). b Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, USA. c R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA. d Global Health Initiatives, University of Maryland, Baltimore, USA. Correspondence to Jon Mark Hirshon (e-mail: [email protected]). (Submitted: 9 September 2012 – Revised version received: 7 January 2013 – Accepted: 11 January 2013 – Published online: 31 January 2013 )

386 Bull World Health Organ 2013;91:386–388 | doi: http://dx.doi.org/10.2471/BLT.12.112664 Perspectives Jon Mark Hirshon et al. The role of acute care in health systems

Fig. 1. Domains in acute care Acute care plays a vital role in the prevention of death and disability. Prima- ry care is not positioned, and is frequently unable, to assume this role. Within health Emergency systems, acute care also serves as an entry b care point to health care for individuals with Trauma care Urgent carec & acute care emergent and urgent conditions. A strict surgerya definition of acute care will allow the Acute care development of metrics for the evalu- Short-term ation of acute care services, the assess- Critical stabilizationd ment of the disease burden addressed f care by these services, and the articulation of Prehospital goals for the advancement of acute care caree in low- and middle-income countries.8 The separate and currently fragmented a Treatment of individuals with acute surgical needs, such as life-threatening injuries, acute appendicitis specialty areas grouped under acute care or strangulated hernias. have been largely unable to spark growth b Treatment of individuals with acute life- or limb-threatening medical and potentially surgical needs, in their respective clinical domains at the such as acute myocardial infarctions or acute cerebrovascular accidents, or evaluation of patients with abdominal pain. international level. This is partly because c Ambulatory care in a facility delivering medical care outside a hospital emergency department, usually of lack of appropriate metrics and coordi- on an unscheduled, walk-in basis. Examples include evaluation of an injured ankle or fever in a child. nation of health service delivery. Under- d Treatment of individuals with acute needs before delivery of definitive treatment. Examples include standing acute care as an integrated care administering intravenous fluids to a critically injured patient before transfer to an operating room. platform allows these splintered areas to e Care provided in the community until the patient arrives at a formal health-care facility capable of giving definitive care. Examples include delivery of care by ambulance personnel or evaluation of acute move forward with a single agenda as a health problems by local health-care providers. unified front. f The specialized care of patients whose conditions are life-threatening and who require comprehensive care and constant monitoring, usually in intensive care units. Examples are patients with severe respiratory problems requiring endotracheal intubation and patients with seizures Key next steps caused by cerebral malaria. Many simple, effective and inexpen- sive acute care interventions can be The contribution of The predominant conceptual frame- life-saving, often within the first 24 acute care work divides health problems into com- hours. Among them are those that municable diseases, noncommunicable are provided at basic surgery wards in As a clinical service, acute care responds diseases and injuries. The current global district hospitals offering treatment for to immediately life- or limb-threatening discussion concerning noncommuni- trauma, high-risk pregnancy and other health conditions, regardless of their ul- cable diseases illustrates how care can common surgical conditions.9,10 Discus- timate cause. Thus, acute care necessarily be fragmented when the time sensitivity sion surrounding acute care is moving supports progress towards strong health of curative interventions is ignored. Of forward owing to visionary efforts such systems (horizontal approach) rather than the 57 million deaths in the world in as the formation in 2009 of the African from patchwork efforts that may improve 2008, 36 million (63%) were caused by Federation for Emergency Medicine outcomes for specific conditions but not noncommunicable diseases.5 A substan- and the Academic Emergency Medi- the overall functioning of the health tial and increasing proportion of the cine Consensus Conference (devoted system (vertical programmes). Notably, global deaths from noncommunicable to “Global health and emergency care: many of the material, consumable and diseases and injuries occurs in low- and a research agenda”), scheduled for May human resources required to implement middle-income countries undergoing 2013. Still, several important steps need acute care platforms are the same as those the epidemiologic transition.6 Strategies to be taken to further the development needed in traditional “disease-centred” for addressing morbidity and mortality of acute care. They include: programmes. Additionally, it is important from noncommunicable diseases have • Creating an acute care service deliv- to dispel common misperceptions about focused almost exclusively on preven- ery model for low- and middle-in- acute care, such as believing it to be the tion and primary care. For instance, the come countries that will function in same as ambulance transport or funda- recently published Prevention and control parallel with preventive and primary mentally reliant on high technology. On of noncommunicable diseases: guidelines services. These acute care services the contrary, excellent acute care is driven for primary health care in low-resource will address both life-threatening by a temporal element – i.e. responding settings offers guidelines for the man- and limb-threatening problems as to immediate threats to life or limb – and agement of diabetes.7 However, only the well as exacerbations of priority involves a redistribution of resources three final points refer to time-sensitive noncommunicable diseases. to minimize impending death and dis- measures, even though a condition such • Improving coordination between ability. The integration of acute care with as diabetic ketoacidosis can be acutely deliverers of acute care services, preventive and primary care completes life-threatening. The essential contribu- such as emergency physicians, sur- a health-care system paradigm that tion of acute care towards reducing the geons and obstetricians, to deliver fully encompasses all essential aspects growing burden of disease and injuries critical acute care services efficiently of health care delivery. has been woefully underestimated. and effectively.

Bull World Health Organ 2013;91:386–388 | doi: http://dx.doi.org/10.2471/BLT.12.112664 387 Perspectives The role of acute care in health systems Jon Mark Hirshon et al.

• Developing research methods of acute care systems towards the care Acknowledgements to quantify the burden of acute of patients with communicable and The authors thank Linda J Kesselring for care diseases and injuries, includ- non-communicable conditions and her valuable assistance. ing health economics and cost- injuries. However, the creation of such effectiveness components, to justify acute care systems should not be used Funding: JM Hirshon received funding integrating acute care within health as a pretext for diverting resources to from the National Institutes of Health systems. the construction of poorly-resourced Fogarty International Center (Grant • Holding national and international and ill-managed health facilities. 5D43TW007296). discussions to encourage better Aligning key players, both within integration of acute care within local countries and across them, to support Competing interests: None declared. and national health systems. the development of the best mix of acute and preventive services needed This paper is a call to action for to address the growing disease burden leaders, policy-makers and academics is an urgent priority for health systems to acknowledge the key contribution and society. ■

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Corrigendum In Volume 91, Issue 3, March 2013, on page 169: the incidence of hospitalization for viral pneumonia among children aged 1-4 years in the pre- vaccine era (July 1998 to June 2004) should be 770 per million person–years (originally published as 591).

388 Bull World Health Organ 2013;91:386–388 | doi: http://dx.doi.org/10.2471/BLT.12.112664