Allison Booher
A Comparative Study of Emergency Medicine in Honduras and Chile
Allison Booher, B.S./B.A. 2021 Vanderbilt University
Abstract
According to the World Health Organization (WHO), 16,000 people around the world die every day from trauma. In recent decades, there has been an increase in efforts to develop the international field of Emergency Medicine (EM). Unfortunately, this development has occurred disproportionately in high- and high-middle-income countries, creating a global economic disparity in trauma care and patient outcomes. According to the United Nations, the expansion of associated initiatives among Latin American countries has led to significant economic growth in the region. Chile, a high-income nation that has experienced a development explosion for its Emergency Medical system in the past twenty years, has been a leader in progress initiatives associated with nearby countries.
This brief study analyzed both quantitatively and qualitatively the differences between some key elements of the public emergency in Tegucigalpa, Honduras, and Santiago, Chile, focusing on two main urban hospitals. A series of interviews with healthcare providers and an assessment of alignment with WHO standards were conducted in both hospitals. The goal of the study was to determine if there are potential growth areas for UM systems in the two cities, especially in low-income countries such as Honduras.
Based on existing literature that suggests a global trajectory of specialization as a prerequisite for healthcare development, it was hypothesized that the comparison of both quantitative factors of Emergency Medicine and qualitative interviews of Emergency Medical personnel will indicate that the EM specialization is a practical and fundamental step for development. In both countries, the interviews with providers indicated that specialization, namely having an Emergency Physician overseeing the Emergency Department, had the potential to streamline the EM continuum of care. Despite significant disparities in wealth and political stability between Honduras and Chile, the implementation of specialized training for physicians, while being mindful of the respective availability of resources in a particular healthcare system, could be a reasonable step for the development of Emergency Medicine worldwide.
Background
The field of Emergency Medicine has become well-established in developed regions of the world within the past half-century, but on a global scale, the specialty is still nascent, especially within Latin America. In Chile, the first Latin American nation to transition from developing to developed nation status in 2010, the realm of Emergency Medicine (EM) has rapidly advanced over the past 20 years. Chilean EM is regarded internationally as the leader in the Latin American field. However, in Latin American countries such as Honduras, still recovering economically from its devastation by Hurricane Mitch in 1998, the prehospital scene seems to have been left in the dust of the developmental boom for EM in Chile. This study will examine the gaps in the quality of prehospital care between the greater metropolitan areas of Tegucigalpa, Honduras, and Santiago, Chile. The analysis will aim to determine the next practical steps for Honduras to develop the infrastructure necessary to organize and advance its Emergency Medical system.
Worldwide, the EM field has emerged and followed several clear trends over the course of the past 50 years. Systems of Emergency Medicine can be qualified as Underdeveloped, Developing, or Mature. In a country with an underdeveloped emergency medical system (Honduras included), EM is not a recognized specialty, there is no system of EM education, emergency departments are staffed by students and physicians of other specialties, and the triage system for hospital intake is extremely simple. For a developing EM system, the recognition of the specialty requires specialized emergency physicians, with academic (residency) systems and an EM national society in place. Emergency departments are frequently directed by emergency physicians, but more mature management is not yet instituted. The Chilean EM structure is at the more advanced end of the spectrum for a developing EM system. Finally, a mature EM system is expansive, further sub-specialization has taken place, and board certification and academic systems have emerged for the field.
For this study, Chile serves as a model for rapidly developing Emergency Medicine. Chilean healthcare is divided into the private and public sectors, and the national health foundation (FONASA) serves 80% of Chileans As of 1990, no EM specialty in Chile. First formal EM training program in 1994, and by 2005, the Chilean population visited the Emergency Department 18 million times, even though there were less than 50 trained EM physicians in the country. However, the specialty of EM was formally recognized by the Ministry of Health in 2013, leading to rapid educational and organizational development with the institution of 10 national training programs. To reach the status of a developed emergency medical system, further steps include creation of Spanish-language academic journals, increased specialization, and unified EM evaluation.
On the contrary, Honduras models the underdeveloped EM structure. Honduran healthcare is also divided into the private and public sectors. Public health services are accessible to 60% of the Honduran population, but public hospitals have lower quality of care with higher infection rates, so the private (for-profit) sector is utilized by those who can afford it. Emergency Medicine is not a recognized specialty in Honduras, and there is only one emergency physician in the country, but the individual works in private medicine. Thus, there are no EM specialists in public hospitals, and no residency or educational program for EM. Healthcare infrastructural issues (lack of resources, fewer providers, disorganized hospital systems) contribute to lower levels of care. Highlighting the deficit of providers, in Honduras, there are 10 doctors and 3.8 nurses per 10,000 inhabitants (compared to LA average of 17.6 doctors, 14.3 nurses).
Structure/Design
This study began as an attempt to address several preliminary research questions. Can the Emergency Medical systems of Honduras and Chile be meaningfully compared? How do the economic, political, and cultural distinctions between Honduras and Chile cause disparities in their potentials for EM development? How might an Underdeveloped EM system be informed by the steps taken for growth in a Developing/Mature EM systems? What are the deficiencies and successes of EM in both Chile and Honduras?
To assess the healthcare provider perspective on the development of public Emergency Medicine in Honduras and Chile, a paired, multimethod approach was applied in top-level metropolitan trauma centers in both countries. The subject hospital in Tegucigalpa, Honduras, was Hospital Escuela Universitario (HEU), the capital’s principal public teaching hospital. In Santiago, Chile, the study took place at the Hospital Urgencia Asistencia Publica (HUAP), the capital’s oldest public teaching hospital with a primary focus on Emergency Medicine.
The two-pronged approach began with a quantitative analysis of indicative factors of emergency healthcare (i.e. providers per capita, patient burden, average wait times, and mortality rate), as well as an assessment of each hospital’s alignment with World Health Organization Guidelines for Essential Trauma Care (WHO 2004). The primary analysis for this study consisted of 20 interviews with a broad range of healthcare providers at each hospital (i.e. nurses, general physicians, specialists, paramedics, etc), aiming to find comparative perspectives between the HEU and the HUAP. A questionnaire was followed with prompts on current EM accessibility, recent changes in the system, EM deficiencies in their hospital, and the impact on specialists on the level of care.
Following the completion of the study, a qualitative analysis of the anecdotal evidence uncovered in the interviews took place in addition to a statistical comparison of the quantitative data.
Results
Each hospital Emergency Department attended to approximately 250-300 patients per day. The facilities had similar numbers in terms of staffing, with more personnel at the HEU but no Emergency Physicians, which were present at the HUAP. The occupancy was almost twice as large at HEU, with approx 70 beds and stretchers for patients, with similar severity in patient condition between hospitals. The severity of cases was comparable between hospitals, and approximately 75% of cases were categorized as mild. Highlighting disparities in efficiency, patients at HUAP stayed in the ED between 5 hours and 5 days, while patients at HEU stayed between 8 hours and 3 weeks. The HUAP utilized the Emergency Severity Index (ESI) system of triage, while HEU used Manchester Triage system.
In Honduras, providers were primarily concerned about the lack of resources and personnel in the hospital. Surgeons were accustomed to reusing single-use medical equipment, such as airways and venturi masks. If a resource or medication was not present at hospital, the patient or their family had to go purchase the item somewhere else to be used in the HEU. There were not enough beds for patients, and only the triage bay and critical observation were air-conditioned. One attending surgeon lamented that the hospital was run by students with limited training. Within the Emergency Department, there were separate wings for cases deemed to fall into the categories for mild and severe internal medicine, surgery, and orthopedics. Once a patient was triaged and sent to a wing of the ED, there was no communication between surgical or internal physicians regarding the details of their case, as there was no electronic medical record (EMR) system in place. Several subjects mentioned that patients would sometimes be sent back and forth between the surgical floor and the internal medicine floor if their case was too complex and the triage was incorrect. Providers felt that they were not given enough time to meet a patient’s needs before being responsible for the next patient. Several physicians cited the absence of emergency specialists as a limiting factor in the quality of care offered by the HEU.
In Chile, recent funding and renovations for the HUAP allowed for a fully-operational hospital, and all providers said that resources were sufficient. Unlike the HEU, the HUAP had air-conditioning, single use equipment, and a well-stocked pharmacy. The hospital had an integrated Emergency Department, with organized triage flow and an EMR system. The hospital’s newly constructed emergency tower facilitated a smooth continuum of care, but some providers thought that the new observation system reduced patient privacy. Similar to the HEU, there was a lack of space to take in more patients, and patients were delayed in treatment and admission due to hospital capacity. The lack of personnel was a main deficiency in the system of emergency care, with specialists split between surgery and consults. The Emergency Department was overseen by two Emergency Medical physicians on each shift, and the presence of emergency physicians was viewed as essential (many providers cited a significant reduction in critical care mortality).
Conclusion
The rampant corruption within the Honduran government has caused stagnation in the public healthcare system, and the barriers to health caused by the lack of funding for basic resources at the HEU can only be overcome by governmental restructuring. However, based on the provider interviews, an overarching theme at the HEU indicated that regardless of the differences between the two nations, public healthcare in Honduras could significantly benefit from a boom in the specialty of Emergency Medicine, similar to that which has occurred in Chile. Providers emphasized the benefits of division of care With clear leadership in emergency care, better communication and patient flow can be established, reducing the burden on providers and improving outcomes for all.
The limitations of this study included a small scope of study for broad analysis, limited time and small sample, and challenges in engaging local buy-in for long-term research. In the future, I hope to pursue research that includes a more rigorous quantitative analysis, looks at broader systems of Emergency Medicine, and conducts a third comparison with an American Emergency Department.
References
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Bast, Haley E., and J. Lee Jenkins. "Challenges to Prehospital Care in Honduras." Prehospital and Disaster Medicine33, no. 6 (December 24, 2018): 637-39.
Chediek, Jorge, and Bernardo Kliksberg. "Propagating South-South Cooperation in Latin America." UNOSSC. September 18, 2018.
Fields, Wesley. "Field Report: Lessons from Chile's 2-Tiered EM System." Emergency Physicians Monthly. 2018.
"Honduran Capital Tegucigalpa to Boost Emergency Health Care with IDB Help." IADB. December 12, 2018.
Mallon, W.K., R. Valenzuela, R.J. Salway, J.M. Shoenberger, and S.P. Swadron. "The Specialty Of Emergency Medicine In Chile: 20 Years Of History." Revista Médica Clínica Las Condes 28, no. 2 (2017): 163-69
Acknowledgements
I am grateful to Dr. Carlos Fortin and Dr. Jorge Ibañez for their support and facilitation as I navigated the conduction of research in their respective hospitals. Thank you to my advisor, Dr. Nicolette Kostiw, for your encouragement throughout the research process.
This project was funded by the Vanderbilt Center for Latin American Studies through the Simon Collier Travel Award.
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About the Presenter:
Allison is a Junior in the Vanderbilt College of Arts and Science, double majoring in Latin American Studies and Neuroscience. She grew up visiting family friends in Honduras, and from those trips her passion for Latin American culture and for health equity in the region took form. She is a medical Spanish interpreter at a nonprofit clinic in Nashville and a NREMT certified volunteer Emergency Medical Responder with Vanderbilt Lifeflight. The Simon Collier grant from the Center for Latin American Studies allowed her to combine these major interests into an independent, international research project in the summer of 2019. Her other research involvements are with the Latin American Public Opinion Project and the Emotions and Anxiety Research Laboratory, where she currently works as a research assistant.