Introduction
Emergency service is defined as public organizations, such as the police, fire brigades, and ambulance, that provide a quick and timely response and deal with emergencies. Countries across the globe vary greatly in the quality of emergency service, especially when it comes to health care. As Khorasani-Zavareh, Mohammadi, and Bohm (2018) state, pre-hospital management remains far from ideal in many parts of the world, particularly in the countries belonging to the low- and middle-income categories. As of now, there is enough data gathered on the quality of pre-hospital care around the globe, which allows for deep analysis and comparison.
This paper deals with the state of emergency services in Riyadh, Saudi Arabia, and contrasts it to countries with better and worse indicators. Apart from that, the paper discusses the key factors affecting emergency service delivery time and applies them to Riyadh.
Saudi Arabia’s and Riyadh’s Standing Compared to Other Countries
Saudi Arabia, officially known as the Kingdom of Saudi Arabia, is a country in Western Asia located in the center of the Arabian Peninsula. According to the WHO’s health profile, the current population of the kingdom is at 32,3 million. The life expectancy at birth is 74 and 76 years for men and women respectively. The total health expenditure amounts to 5.8% of the country’s GDP. As of 2017, Saudi Arabia had risen to the 39th position out of the total of 189 in the Human Development Index (HDI) rating. The rating assesses how efficient the country is in realizing its population’s human capital, and the most recent results put Saudi Arabia among the most developed countries.
Main body
The WHO’s most recent healthcare efficiency ranking put Saudi Arabia at the 26th position out of the total of 191 positions (Tandon, Murray, Lauer, & Evans, 2000). The countries with the closest health indicators are Cyprus, Germany, the United Arab Emirates, and Israel. Today, the kingdom of Saudi Arabia houses 18 ambulance stations with an average response time of 13 minutes. This indicator is relatively good; however, Saudi Arabia is well behind such countries as Japan (5 minutes), South Korea (5 minutes), and Australia (8 minutes). Besides, the global average is currently at eight minutes and the ideal response time is at four. Still, as compared to Bangladesh (175 minutes), Greece (28.9 minutes), and Malaysia (25.65 minutes), the kingdom is showing outstanding results.
However, some studies show contradictory findings regarding the quality of medical services in Saudi Arabia. For instance, recent research by Villanueva, Almadani, Mahnashi, Alyhya, and Alshreef (2017) has revealed that more than 40% of patients in Riyadh had to wait for more than twenty minutes. Given that Riyadh is the country’s capital and the city with the most resources to serve its population, remote regions must be suffering even more.
Villanueva et al. (2017) argue that there are various reasons for subpar emergency services in Riyadh. The main factors outlined by the researchers are complicated registration procedures, a low number of staff at the counter, and not enough doctors in general. If Saudi Arabia, and particularly its capital, Riyadh, wishes to improve this health indicator, it should resolve the unique challenges that it is currently confronted with.
Emergency Service Delivery Time: Best and Worst Countries and Contributing Factors
The Japanese healthcare system is considered to be one of the best in the whole world. According to Kim, Gaukler, and Lee (2016), the current legislation requires the national and local governments to ensure the provision of high-quality medical care. Zhang and Oyama (2016) state that the government has long been pressed to increase health expenditures, and so far, it has been responding well to the country’s public health challenges. Serving Japan’s large population might not be an easy task for emergency services. What really helps reach out to as many citizens as possible is the country’s well-developed infrastructure.
In actuality, based on this criterion, Japan ranks fourth, behind Hong Kong, Singapore, and the Netherlands. Besides, despite the aging population, Japan is not currently experiencing shortages in the medical workforce. As stated in the report by the World Health Organization (2017), Japan carefully regulates the supply of doctors, nurses, and other healthcare professionals based on yearly supply-and-demand projections.
In contrast, Bangladesh seems to be struggling to meet its population’s health needs. According to Joarder, Chaudhury, and Mannan (2019), the government fails its citizens at many levels. As of now, 5.9 million Bangladeshis are forced to live in extreme poverty, which Joarder et al. (2019) partly tie to the poor quality of health care. The researchers state that the country has yet to ensure equal access to medical services for all its citizens. A densely populated country, it has an extremely small number of ambulance stations. This may be explained by the inadequate resource and finance allocation. Joarder et al. (2019) conclude that transforming the Bangladeshi healthcare sector will require a collective effort of other sectors and new initiatives from the government.
The Current State of Riyadh in Terms of Emergency Care Delivery Time and Key Contributing Factors
Emergency service delivery time is defined as the time the ambulance spends between receiving a call or a request in any other form and arriving at the scene. Delivery time is considered to be one of the key quality indicators as it impacts the survivability of the patients. The World Health Organization (2019) states that many health interventions are extremely time-dependent. Sometimes a matter of mere minutes may decide if a person lives or dies. For this reason, the World Health Organization (2019) made it a point to outline the key factors that affect emergency service delivery time. Since Saudi Arabia has been the WHO’s long-term collaborator, the guidelines might be applicable.
Adding the System to the Services
The first factor defined by the WHO is the presence of well-planned emergency services within the health systems of a country. Contrary to popular belief, the implementation of innovative emergency care services is not that costly in the grand scheme of things. Moreover, even small improvements can lead to considerable results in the long run. One of the examples of such improvements is introducing a clear and comprehensive triage protocol for emergency work staff.
Such a protocol may cover the transportation procedure and reduce delays in life-saving intervention. Another use of a protocol is risk group identification and prioritization based on expected health outcomes. Becker et al. (2015) conducted a study in triage protocols for emergency services and concluded that high-priority groups were more likely to be hospitalized and experienced higher mortality rates. The protocol put forward by Becker et al. (2015) based on five levels of condition severity proved to be efficient and applicable to wider populations.
The issue of prioritization is especially relevant for Saudi Arabia where health providers seem to be struggling to differentiate between patients who need urgent treatment and those who do not. What makes the situation even more complicated is that the current level of health literacy does not allow patients to figure out the severity of their condition on their own before contacting emergency services. In a study by Alyasin and Douglas (2014), it was established that around two-thirds of patients delivered to emergency units did not need immediate intervention. Alyasin and Douglas (2014) explored the reasons for their presence at the emergency health units.
As it turned out, the most popular reason was not having access to healthcare other than requesting help through emergency services. Some patients who had a regular health provider contacted emergency services because they wished to be served 24/7 (Ebrahimian, Seyedin, Jamshidi-Orak, & Masoumi, 2014). It is abundantly easy to see how those factors led to an increased workload for emergency work staff. Another obvious consequence of having to handle more patients than needed is delayed in reaching out to those who need a medical professional urgently.
Emergency Care Workforce
Responding to an emergency takes a relevant academic background, professional experience, and personal qualities such as practicality, stress resilience, and health compassion. In its report, the World Health Organization (2019) takes issue with the lack of specialized, comprehensive emergency training in many countries across the board. The WHO states that frontline health workers providing care for the acutely ill often do not have the benefit of dedicated education. Statistically, the majority of pre-hospital care is delivered by specialists trained in other fields.
The WHO acknowledges all these issues and suggests three interventions that could go a long way and make a real difference for those countries that struggle with improving emergency health care. First, there is a need for specialized medical programs and certifications that would make a health worker eligible for work at emergency units. Second, medical facilities should offer their employees clear pathways for refining their skills and deepening their knowledge.
Apart from that, it is essential that each hospital develops clear protocols for handling a variety of acute situations. In this case, doctors would be able to rely strictly on facts and evidence as opposed to opinion and tradition. Lastly, those in the decision-making positions should seek to promote safe and comfortable working environments for emergency care workers. They should not be strained by the lack of necessary resources, violence, or exposure to health hazards.
Over the course of the last century, Saudi Arabia has made tangible progress in developing its emergency workforce. As Khattab et al. (2019) point out, in Saudi Arabia, emergency medicine is a young field that first emerged in 1934. Since then, the country has capitalized on rigor and education to supply the workforce and reach as many people as possible. The kingdom recognized emergency medicine (EM) as an independent specialty in 2000.
In the same year, a coordination committee was established and the training program of its first four residents was launched. Riyadh played an important role in the development of the field as it housed the residents and provided training in the Health Affairs and King Faisal Hospitals. Four years later, in 2005, one more body was formed – the Saudi Board of Emergency Medicine (SBEM). Today, the SBEM oversees and accredits EM residency programs in 22 training centers across the country.
When it comes to medical education, Saudi Arabia makes a conscious effort to keep up with the world’s most developed countries. For instance, emergency care providers take simulation-based training courses, which have been recognized as evidence-based practice globally (Khattab et al., 2019). Simulation is being increasingly integrated with residency programs – an initiative that started in the country’s major cities such as Riyadh. The SCFHS plans to expand the program to reach cities and regions not so rich in resources as well. As of now, the Saudi healthcare sector is testing mobile simulation trucks that can be taken to peripheries to train emergency work staff there.
As was mentioned earlier, one of the main reasons for subpar emergency service delivery time is understaffed medical facilities. Khattab et al. (2019) explain that the healthcare sector might be experiencing staff shortages due to the suboptimal work environment. The researchers outline three factors that have shaped emergency medicine in Riyadh and Saudi Arabia as a whole:
- The slow pace of development. Despite passing major milestones in 2000 and 2005, innovative emergency medicine guidelines have yet to be translated into practice. According to Khattab et al. (2019), many Riyadh facilities are using outdated methods of handling emergencies, which ends up in delays;
- Poor human resource management. At many facilities, emergency medicine has yet to be taken seriously. More often than not, emergency units employ new medical staff and become a sort of “boot camp” before they are assigned to other floors. Khattab et al. (2019) claim that in some cases, emergency units are staffed with underperforming employees;
- Lack of awareness. Leadership in health care suffers from the lack of acknowledgment of the importance of emergency care services. Since they are often neglected – both in the capital and in remote regions, they are understaffed and underfunded;
- Dependence on the expatriate workforce. Saudi Arabia may be a lucrative place for health workers coming from poorer countries. However, they do not tackle the shortage problem due to their mobility. Riyadh and other cities cannot and should not depend on foreign workers or justify their inaction citing a high percentage of the expatriate staff.
The Use of Big Data
Yet another that may decide the outcome of an emergency is how well a medical facility handles patient data. The World Health Organization (2019) argues that improving outcomes depend to a large extent on the proper utilization of health information. The use of big data in medicine may mean clusterization of patients into risk groups and predictive modeling for taking preventative measures. According to the World Health Organization (2019), the most vulnerable aspects of emergency care are undifferentiated presentation characterization and the identification of acuity level. In the report, the WHO provides a clear example: there is a difference in resource allocation for a child with cough and fever and a child with respiratory failure.
It is readily imaginable how the symptoms of these two conditions may be easily confusable when reported over the phone. The WHO suggests that health organizations start documenting consistently and accurately and take a systematic approach toward data logging. As for practical implementation, the WHO claims that it has already developed tools that its collaborators, Saudi Arabia included, can use.
Predictive analytics may help to identify risk groups among the population of Riyadh and reinforce emergency service presence strategically. Saudi Arabia has already been implementing digital technologies in different sectors, and quite successfully so. However, for a number of reasons, health care is still lagging behind. According to Alharthi (2018), the kingdom will only approach the realm of big data analytics when hospitals will have functional electronic medical record (EMR) systems in place. As of now, it is not exactly the case: even Riyadh’s healthcare facilities still depend on physical documentation that cannot be easily transferred or researched.
Even though the initiative aiming at bringing technology to hospitals was launched more than ten years ago, its objectives have yet to be met. Alharthi (2018) reports that between 2007 and 2011, Saudi Arabia failed 52 healthcare IT projects, wasting $10 million. The most likely inhibitions are regulatory and financial as there is not a unified body that could oversee the progress and allocate costs. Apart from that, the medical staff lacks the skill to handle hardware and software.
Readiness for Extraordinary Events
One of the key indicators of a functional emergency care system is its readiness to handle so-called extraordinary events. The World Health Organization (2019) classifies armed conflicts, natural disasters, and outbreaks as extraordinary events. In the report, it is stated that if an emergency system is barely functional on a normal day, during events such as those mentioned earlier, it may as well collapse. The World Health Organization (2019) associates the breakdown of emergency systems when they are needed the most with acute and preventable mortality. Thus, it is essential to work on refining emergency services and train the working staff to be ready to face catastrophic events.
As of now, Saudi Arabia is not entirely prepared to handle extraordinary events. In his book, Gray (2014) names the main reasons for less-than-perfect public security in the kingdom:
- The kingdom has yet to develop effective ways to manage religious mass gatherings such as Ramadan and Hajj. Gray (2014) argues that crowded sacred places compromise public security, and the government has not yet come up with a solution. According to the researcher, one way to go about the issue is to establish helicopter bases, i.e. flying ambulance, which at least, the capital city, Riyadh, might be able to afford;
- Natural disasters are still seen as a rare and low-impact type of emergency. In case of a flood or other extraordinary event, the ambulance may have a hard time coming through, especially if the roads are closed down;
- Not enough coordination between responsible institutions, i.e. parties providing infrastructural services, such as power cables, telephone cables, and draining pipes.
Conclusion
The importance of pre-hospital care is hard to dismiss: statistically, the majority of deaths occur before hospitalization. Well-organized and coordinated emergency systems account for both short-term and long-term positive outcomes. In the short perspective, they prevent injuries, complications, and deaths. In the long run, well-planned pre-hospital systems prevent disabilities and lasting psychological traumas, benefitting both patients and health providers.
As of now, Saudi Arabia shows decent emergency care metrics, namely, a response time of 13 minutes. However, some other studies negate this piece of statistics and argue that the actual delivery time amounts to no less than twenty minutes. As compared to Japan, Saudi Arabia experiences more problems with infrastructure and medical staff shortages. Among other problems are barriers to big data use and the lack of comprehensive emergency medicine education. Yet, the kingdom is way ahead of countries such as Bangladesh that is nowhere near providing its people with equal access to health care.
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