Emergency medicine in Saudi Arabia: a century of progress and a bright vision for the future

The first fellowship to be established was the pediatric EM fellowship, which is a 2-year program that accepts graduates of both EM and pediatric boards. It began in 2006 and has several approved training sites across the KSA, all of which have fully dedicated pediatric emergency departments. The goal of this fellowship is to prepare graduates for all the possible emergencies seen in children aged 0–14 years, which is the upper limit for pediatric patients in the KSA, building on the pediatric training the EM residents received during residency. Two new fellowships specially designed for EM graduates are provided by the ED of Ministry of National Guard Health Affairs Hospital: a 2-year combined EMS and Disaster Management fellowship and a 1-year Emergency Ultrasound fellowship. The first prepares graduates to become competent directors of EMS departments as well as disaster and mass casualty response teams. The second prepares graduates with the competencies required to become bedside ultrasound directors, trainers, and quality assurance specialists for EDs.

The need for trained EM providers is huge but the number of SBEM graduates is still not enough to cover many regions in Saudi Arabia, especially rural and peripheral areas. A 2-year diploma in EM was started in 2017. It is a postgraduate training program with 13 blocks per academic year in which the trainee undergoes in clinical rotations similar to the first 2 years of the SBEM in addition to the Hajj rotation. After successful completion of 2 years of training and passing the final oral and written exams, the trainee will be recognized as a registrar by the SCFHS [11].

The MoH, through its Emergency Departments Support Program (EDSP), has implemented an organized education outreach program, also called a boot camp course, for the education and training of general practitioners (GPs) working in peripheral EDs with the aim to improve and update the current practice of GPs regarding the most recent EM research.

The SCFHS identifies EM (consultant) attending as a board-certified emergency physician who completed residency training in EM. Practicing EM attending physicians received their residency training locally, in the SBEM, or internationally in different countries such as the USA, Canada, Australia, South Africa, and France. Another subset of EM attending physicians is certified by the Arab Board of Emergency Medicine, which is regulated by the Arab Board of Health Specialization. Still, in the KSA, there is a massive need for certified EM physicians. To date, some hospitals and even cities still do not have a certified emergency physician working in the EDs and GPs or physicians who are internal medicine or general surgery training are acting as ED team leader.

In the KSA, simulation-based learning has begun to be utilized by some academic hospitals with institutional capabilities and resources for simulation education. Bootcamps for emergency medicine residents are organized yearly to deliver a focused training for major EM procedures using simulation. A SCFHS project to integrate simulation-based learning in residency training, including EM residencies, is currently underway. A focus group conducted educational needs assessment to develop specialized simulation-based courses. Courses are designed and developed by EM physicians with medical education and simulation background. The program started in cities that have resources for running simulation courses, and have the opportunity to expand further. For instance, a mobile simulation truck is developed for future use to conduct simulation courses in the peripheral facilities without simulation resources, which holds promise for the improvement of EM training in underserved regions.

The only society for EM physicians in the KSA is SASEM, which is affiliated with the SCHS. It was formed in 2008 and is run by a board of emergency physicians. It provides working groups for EMS, ultrasound, disaster management, toxicology, EM nursing, trauma, and critical care. It also runs the annual SASEM conference hosted in a variety of cities across the country, which is the main gathering of EM physicians in the KSA. Other notable symposiums include the Saudi Emergency Medicine Assembly (SEMA) and Best of EM, which are organized annually by groups interested in education. The training sites offer a large number of workshops specific to the practice of EM in the fields of bedside ultrasound, airway management, EM and surgical procedures, resuscitation, and emergency radiology. There is Saudi Association of EMS affiliated with SCFHS.

One way to achieve this goal involves other providers filling the existing gap in care, particularly primary care physicians (PCPs), urgent care facilities, home healthcare, and rehabilitation services. Urgent care can provide quick access to medical care, including after-hours (when a patient needs healthcare but cannot see their PCP and is faced between going to the ED or waiting until morning to use primary healthcare services). Urgent cares can also release some of the burden placed on EDs and fill in during PCPs’ off hours, which can be quite useful to patients. Moreover, improved primary care and referral systems (i.e., follow-up) can relieve some of the pressure placed on EDs. Understanding the barriers and enablers to accessing primary healthcare will likely help reduce inequalities in access to and utilization of primary healthcare, especially suburban and rural populations. Strengthening and monitoring of the follow-up system and the communication between PCPs and EDs is one way to overcome the barriers faced by PCPs. For example, among patients who reported being frequent users of EDs, approximately one third cited the “availability of modern diagnostic equipment” (37.3%) and “to avoid taking time off from work” (33.0%) as reasons for using EDs [22]. Findings like this suggest that better resource in the hands of PCPs and more available hours (whether met by PCPs or urgent care facilities) are two of the key enablers that could encourage more patients to seek primary care rather than always immediately going to the ED. Finally, home healthcare and rehabilitation services are also underdeveloped in the KSA and, as such, present an opportunity to expand services and relieve the burden faced by hospitals and particular EDs.

In addition to increasing access to healthcare, the KSA has many opportunities to improve the quality of healthcare provided. One way to improve healthcare quality is to enhance patient flow coordination and facilitation. This enhancement could be achieved through measures such as establishing the role of a “bed czar” or patient flow manager. This person would be responsible for ensuring timely transfer of ED patients to assigned inpatient beds. Assigning a dedicated nurse with admissions/discharge/transfer duties who is specifically responsible for facilitating discharges to accelerate available beds for admissions. Furthermore, the development of accelerated triage and registration processes based on patient’s acuity could reduce waiting times [23]. Along the same lines, early discharge can improve flow and can be achieved in a number of ways, including:

Flow is of the utmost importance to high quality are and is prioritized in most quality assurance (QA) objectives. Flow, or lack thereof, is also a factor in waiting time and triage procedures in EDs Waiting times can have a dire impact on high acuity patients. Long waiting time is associated with delays in time-sensitive treatments for serious conditions typically requiring admission [24]. Many EDs use a physician-in-triage (PIT) process to overcome the negative impacts of patient waiting time on patient care quality and efficiency.

Diversion management and reduction is still another way the quality of healthcare can be improved. This improvement requires establishing new protocols and monitoring systems to allow early warning when the system is approaching its maximum capacity and its threshold for diversion. Additionally, this would necessitate developing a hospital-wide diversion response protocol to focus existing resources on facilitating all appropriate patient discharges in a timelier manner. Finally, the creation of a community-wide diversion plan in collaboration with local hospitals and the community’s emergency medical services unit could help establish a common protocol for hospitals going on and off diversion or bypass [23].

In addition to enhancing access to healthcare through diversification of options and emphasis on primary care, improved provision of healthcare in the KSA can also be achieved through better EMS education, training and staffing. One problem with EMS is that the majority of EMS calls are for relatively minor complaints or non-medical complaints. For example, a recent study of EMS transport calls found that an alarming 25% of calls made during the study period were reported as non-transported calls. Of those, 70% stemmed from refusal by patient while 22.4% of were canceled by dispatch [25].

Gender also plays an important role in the quality of EMS care. In a conservative nation like the KSA, the care provided to men and women can be disparate. For example, the ratio of males to females in EMS calls was 2:1; males accounted for 722 calls (51.9%) while females accounted for only 325 (23.4%). In a significant number of cases, the gender was not listed [25]. The lopsided ratio is likely because a vast majority of females arrived by private vehicles. In light of this disparate ratio and with the recent change in the KSA allowing women to drive, the need for female EMS personnel has become abundantly clear.