Building the next generationof emergency care systems
Ensuring health systems have the right building blocks
to develop effective emergency care systems for the future

August 2021

Content
Executive summary

3

1. Emergency care systems – key trends

5

2. Emergency care systems and best practices

9

3. Building next-generation emergency care systems

11

4. Key enablers for the system

13

Authors:
Vikas Kharbanda

Dhiraj Joshi

Partner
Healthcare, Dubai
kharbanda.vikas@adlittle.com

Partner
Healthcare, Dubai
joshi.dhiraj@adlittle.com

Samir Imran

Nitin Kenkere

Principal
Healthcare, Dubai
imran.samir@adlittle.com

Manager
Healthcare, Dubai
kenkere.nitin@adlittle.com

Priyanka Bhageria
Consultant
Healthcare, Dubaibhageria.priyanka@adlittle.com

Executive summary
Delivering emergency care is an integral part of the health system, and the qualityof emergency care has a key role in determining health outcomes for patients.
Emergency care systems operate within the larger healthcare ecosystem and can
only be as effective as the overall system. Across the world, emergency caresystems increasingly use technology to increase their efficiency and provide faster
access to care. However, while today’s emergency and trauma care systems offer
significantly more medical capability than was available in years past, they
continue to suffer from severe fragmentation, an absence of systemwide
coordination, and limited accountability.
This Report outlines the trends in emergency care and proposes key building
blocks for developing a best-in-class and customized emergency care system
to serve future needs.

31. Emergency care systems – key trends
Emergency care includes all immediate and unscheduled carewith varying degrees of acuity:
1. Life-threatening emergencies. Immediate medical
assistance is required to protect the patient from apotentially fatal injury, disability, or death.
2. Emergencies. Medical assistance is required to protect
the patient from further complications.
3. Urgent care. A delay in immediate intervention and patient
conveyance does not impact the medical outcome.
4. Crisis/disaster management. The number, severity, anddiversity of injuries overwhelm local medical resources
and require a cooperative, multidisciplinary effort.
The scope for emergency care is best described using the“chain of survival” shown in Figure 1, which starts with
Figure 1:

bystander response and ends when the patient is finallydischarged or transferred to acute/long-term care. The various
components of this chain are response by bystanders, triagingof emergency calls, provision of emergency medical services,
treatment in the emergency department, inpatient and intensive
care treatment (if needed), and the discharge of patients ortheir transfer to long-term care. The chain is only as strong as
its weakest link, so health systems should focus on all of thecomponents.
Based on the extensive research Arthur D. Little has conductedin collaboration with health authorities, providers, and industry
experts, we have identified eight distinct emerging insights andinnovations that are transforming the way health systems are
reimagining the key building blocks of effective emergency careecosystems (see Figure 2).

Chain of survival

Bystander
response

Triage dispatch
centerEmergency
medical services

Emergency
department

Intensive care
unit/ward

Long-termcare/discharge

Source: Arthur D. Little analysis

Figure 2:

Global trends in emergency care
Improved access topoint-of-care response
devices

Mobilizing andempowering
bystanders

Using artificial
intelligence for triage
and dispatch support

Using point-of-caretelemedicine

Expanding scope of
emergency
departments

Treating ambulanceas the first emergency
room

Integrating systems
across the emergency
care chain

Directing nonemergency care to
low-acuity settings

1

Source: Arthur D. Little analysis

51. Mobilizing and empowering bystanders

3. Using point-of-care telemedicine

Countries across the globe are focusing on improving bystander
response through methods of mobilization and empowerment,
including:Trained bystander populations and faster response mechanisms
are augmented with point-of-care telemedicine systems thatempower and enable more advanced care on site. For example:

n Awareness campaigns (e.g., the US “Stop the Bleed”
campaign).

n Project ETHAN in Houston, Texas, gives fire and rescue
responders a video link to emergency doctors, enabling
doctors to direct patients to the right care and preventing
unnecessary trips by ambulance.

n Compulsory training (e.g., Denmark has implemented
mandatory resuscitation training for elementary school
students and residents applying for a driver’s license).
n Bystander applications (e.g., Sweden launched theHeartrunner application to alert bystander volunteersof a nearby medical emergency).
n Supporting legal environment with bystander-focused laws
and regulations (such as the Good Samaritan Law, a versionof which is in place in several countries across the globe,
encouraging volunteers to provide assistance by offering
legal protection).

2. Improved access to point-of-care response 		devicesApart from educating and encouraging bystanders, time to
first response is being improved by increasing the accessibilityof automated external defibrillators (AEDs) that are being
placed near high-risk population areas where people are more
susceptible to heart conditions. Further, AEDs are being madepublicly available via initiating AED registries, enabling privately
owned AEDs to be used by bystanders in cases of emergencies.
Medical drones may also soon be used to deliver AEDs to
bystanders at the site of incident.
Figure 3:n Medical drones are currently being tested in Sweden thatwill be equipped with audio and video support to enablebystanders to get in touch with emergency physicians for
guidance and assistance.
n In Copenhagen, Denmark, doctors/nurses/paramedics
answer emergency calls and provide guidance to bystanders
handling emergencies until the ambulance arrives.

4. Using AI for better triage and dispatch support
Triage and dispatch centers increasingly use software todetect medical emergencies, optimize planning, and improveprioritization (see Figure 3).
Business intelligence software is being used to provide a realtime overview of resources at hand and to track accurate caller
location. Triage centers in Copenhagen, as an example, are using
Corti, artificial intelligence (AI) designed to detect cardiac arrests.
Corti can help dispatchers reach 92% accuracy when detecting
out-of-hospital cardiac arrests and can detect cardiac arrest an
average of 30 seconds faster than human operators.

Uses of software and AI in triage and dispatch centers
Detection of patient
symptoms

Information gatheringand sharing

Enables the detection ofcardiac arrests 30 seconds
faster as compared to humanoperators

Enables the dispatch center toshare patient’s real-time
condition with the dispatched
EMS unit

Resource planning
Provides real-time overview ofresources at hand and helps
dispatchers allocate resources

Location tracking
Gives dispatchers
immediate location data
accurate up to 3 feet
Source: Arthur D. Little analysis

65. Treating the ambulance as the first emergency
room

7. Directing nonemergency care to low-acuity
settings

To reduce time to treatment, various countries equip
ambulances with specialist nurses, systems to transfer
pre-hospital data to hospitals’ electronic records, miniature
CT scanners, point-of-care blood test labs, as well as
telemedicine that enables paramedics to address conditions
such as arrhythmia, myocardial infarctions, and ischemic strokes.

Countries across the globe are implementing various initiatives
to direct nonemergency patients to the right care, including:n Online primary clinics. Mobile applications provide accessto a general practitioner, 24/7. This reduces the numberof nonemergency care patients who visit an emergency
department due to the unavailability of a primary care
physician.

6. Expanding scope of emergency departmentsn Co-location of emergency departments and primary careclinics. In the Netherlands, all emergency departments
cooperate with primary care clinics, and around 30%
of primary care clinics and emergency departments areintegrated with a common triage process.

As emergency departments are expected to continue to be a
key gateway into the overall health system in the future, they
are expected to expand their scope to include observation units,intensive care units, telemedicine services, access centers,
and home hospitals (see Figure 4). This will enable emergency
departments to develop more patient care settings to better
triage and treat emergency patients.

n Flexible emergency lines. While many countries haveseparate numbers for emergency and nonemergency
requests, in Copenhagen, these numbers are different but
their lines are integrated, thereby enabling dispatchers to
swiftly adjust the level of help required at any given point
in time.

n AI is being used in emergency departments for predictivemodeling, patient monitoring, and day-to-day running of
emergency departments. The University of Virginia Medical
Center uses AI for discrete event simulation and optimizes
its emergency physician schedule to reduce waiting times
in the emergency department. Such use of AI can assist
emergency departments in improving care by decreasing
errors and increasing efficiency.
Figure 4:

Expanding scope of emergency departments
Obs. unit

Procedural unit

1

2

ICU

Obs. unit

Hospital
3
Telemedicine

4ED
Access center
Home hospital
5

Source: Arthur D. Little analysis

47

8. Integrating systems across the emergency care
chain
Patient data, reports, and health status are shared by prehospital settings (e.g., by ambulance) with emergency
departments to enable the emergency department to be readyto receive patients and ensure optimal prioritization of thedepartment’s resources. For example, the Pulsara application in
the US allows emergency medical technicians and paramedics
in the ambulance to share all patient information and data withthe emergency department. Along with the estimated timeof arrival, paramedics are able to share other critical patient
data with emergency departments prior to arrival, such as
electrocardiogram results and reports of injuries. This enables
the emergency departments to prepare and provide better andfaster treatment to the patients when they arrive on site.

8

Similarly in Dubai, the Dubai Health Authority has launched an
application for stroke and myocardial infarction diagnosis. The
Join medical communication app provides faster communication
between paramedics and hospitals, including sharing patients’condition, medical history, health card, and pictures/videos. This
information enables hospitals to be better prepared to receive
and treat patients when they arrive.

2. Emergency care systems and bestpractices
Arthur D. Little studied the emergency care systems ofeight regions – Sweden, the Netherlands, Germany, the UK,
Singapore, Denmark, Boston (US), and Seattle (US) – andidentified their leading practices. We have highlighted the
key learnings from four of those regions below.

The Netherlands
The Netherlands uses incident prediction software to estimate
the number of emergency calls and to relocate emergency
services based on the predicted demand. A distinguishingfeature of the emergency care system is its strong emphasison educational requirements for its medical staff and its focus
on their continuous upskilling.
In the Netherlands, every ambulance is required to have a
specialist nurse and a trained driver technician onboard who
can assist the nurse. Specialist nurses are required to have afour-year nursing degree and one and a half years of emergency
room nursing training. Additionally, to be eligible, nurses musthave a year of experience in emergency department in addition
to at least a year of nursing experience. The driver technician isrequired to have a diploma in first aid. Continuing education isprovided at the national as well as the regional level to upskill
the workforce regularly.

Denmark
Denmark has ensured a high level of integration across thechain of survival and delivers a swift and coordinated Emergency
Medical Services (EMS) response.
The Denmark system has high adaption of technology, including
telemedicine and AI. Denmark introduced various national-level
initiatives to improve bystander response, such as requiring
mandatory training for elementary school students and people
who are getting a driver’s license, distributing instructional kits,
and offering tele-guidance to bystanders. As a result of these
initiatives, Denmark has a strong bystander response, which isreflected in an increase in survival rates (increasing from 4%
in 2001 to 12% in 2019, according to a study published in The
New England Journal of Medicine).
Medical dispatchers in Copenhagen are supported by Corti AI,
which not only has a high rate of accuracy for detecting outof-hospital cardiac arrests, but also offers a pre-hospital record
system developed by Amphi Systems. This record system
automatically transfers pre-hospital data to the hospital’s
electronic records, enabling emergency departments to prepare
for patients’ treatment before they arrive at the hospital. The
system also has access to the patient’s medical history toenable optimal treatment on site.

This combination of ambulance staff allows the emergency
medical services of the Netherlands to effectively treat patientsat the scene and during transportation, while also being costeffective.

9

England (UK)

Seattle (US)NHS England’s disaster management plan provides clear
leadership pathways to effectively and efficiently manage crisis
situations. England deploys the Hazardous Area Response Team
(HART), comprising paramedics who work alongside police andfire rescue services to preserve life at the early stages of anincident (see Figure 5). HART uses the Major Incident Medical
Management System (MIMMS) to strategically, tactically, andoperationally manage mass casualty incidents.

Seattle has one of the highest out-of-hospital cardiac arrest(OHCA) survival rates in the world due to its outstanding
bystander training. (80% of King County’s population are trainedin cardiopulmonary resuscitation [CPR] and are able to respond
to OHCAs.)

Members of HART undergo continuous training and are
based in every one of England’s 11 NHS ambulance trusts(providing ambulance services in England and Wales) and areinteroperable.
HART deployment ensures that patients are triaged, andcasualties treated, at the earliest time possible – thereby
resulting in lives saved that otherwise might have been lost.

Seattle launched the “Shockingly Simple: Restart a Heart” media
campaign to increase the placement and registration of AEDs.
Within the first month of the campaign’s launch, 62 new AEDs
were registered. The King County EMS division undertakes
several CPR education initiatives:n Community-based hands-on CPR education. Training
is made available to groups such as seniors, people withlimited English proficiency, other vulnerable populations, etc.
n Student CPR program. Provides training to around 11,000
students each year.
n King County employee training. Targets employees who
work directly with the public.
n City employee training. Training to all employees who work
directly with the public.
The above initiatives have resulted in 67% of all out-of-hospital
cardiac arrests to be revived by bystander CPR in King County.

Figure 5:

HART response capabilities and specialist training

Specialist training

Types of incidents to which HART teams can respond

NON-EXHAUSTIVE

Hazardous materials
Chemical, biological, radiological, nuclear

3-week residential incident response unit training

Marauding terrorist attack
Working at heights

3-week residential/urban search and rescue training

Confined spaces
Unsustainable terrain
Water operations

3-day inland water operations course

Providing support to security operations

Source: Arthur D. Little analysis*IRU: Incident Response Unit; USAR: Urban Search and Rescue

.

5

10

3. Building next-generation emergency
care systems
Studying these emergency care systems has enabled Arthur D.
Little to determine the best practices across the chain of survival
as well as to identify the ecosystem’s key enablers. Healthsystems can use such information to build a customized
best-in-class emergency care system.
Emergency care systems should apply these insights in thecontext of the current system and specific needs of an area.
There are a number of key building blocks and components thatmust be taken into consideration for building a customized
best-in-class system (see Figure 6).
Figure 6:

Further, departments must identify the structure of delivering
emergency care (i.e., whether it is in close collaboration with thefire department and/or police department or as an independent
medical unit), along with examining the pros and cons of such amodel and structure. Health organizations should also consider
the degree of involvement and readiness of the private sector to
support the delivery of such services.

Considerations for building a customized best-in-class emergency system

Current systemmaturity

Patient caremodel andstructure

Bystander and
EMS capabilities

Emergency
department
distribution andcapabilities

Resource
requirement andavailability

Legal rules andregulations

Source: Arthur D. Little analysis

Current system maturity

Bystander and EMS capabilities

Health organizations must study the maturity and fully
understand the capabilities of the current system to transforma system to best-in-class. They must accurately capture key
metrics such as the survival rates in different stages of the chainof care, time to triage, time to doctor, and so on, and benchmark
these metrics against other mature systems to gain insight into
priority areas for improvement.

Emergency care systems should also consider the population’s
readiness in terms of awareness and training in first aid andoverall culture to provide help. The challenges bystanders face(such as unavailability of AEDs, directions from call centerparamedics, and so on) must be understood and identified.
Additional considerations, such as an assessment of the current
use of technology for the provisioning of emergency medical
services, training of paramedics, policies and procedures
followed, equipment used in ambulances, and so on, should be
carried out and methods to increase accuracy and speed mustbe identified in line with international best practices.

Present care model and structure
There are two main types of emergency care models: AngloAmerican and Franco-German. While in the Anglo-Americanmodel the patient is brought to the doctor in an emergency
department, in the Franco-German model the doctor is usually
brought to the patient, and patients are thereafter admitted
directly into inpatient wards. Different regions usually adopt
different care delivery models, and health organizations muststudy and recognize the implications of the adopted model.

6

Emergency department distribution and capabilities
It is imperative that health systems study the present
geographical distribution and specialization, if any, of emergency
departments to understand whether they under/overserve
specific areas and conditions. Moreover, they must gather

11insight into the current capabilities of emergency departments
in terms of emergency department doctors, nurses, equipment,
beds, time to triage, and so on.

Resource requirement and availability
Health organizations should identify resource requirements andavailability for the system across three key dimensions: financial,human resources, and fixed assets. They should also keep inmind the constraints with respect to resources while laying thefoundation for the vision of the best-in-class emergency caresystem. It is vital as well to determine methods to procure/create the required funds or talent.

12

Legal rules and regulations
During system development, consideration must also be given
to current legislation acts, policies, and procedures in place toguide the provisioning of emergency care services. The new
system’s vision should be in line with the existing legal scopeof service of various players in the chain of survival.

4. Key enablers for the system
Developing a best-in-class system requires the support of afew key enablers that drive the system’s implementation.

Governance and regulation
Integration of the health department(s) and EMS ensures thedelivery of consistently high-quality services. To facilitate thisintegration, one central healthcare body at a regional levelshould govern the entire chain of survival. Moreover, developing
and implementing a robust emergency care system requires
a supportive regulatory framework with clear definitions andstandards for emergency care, protection for bystanders (e.g.,
the Good Samaritan Law), and consistency in guidelines andregulations.

Supportive leadership
The presence of strong and supportive leadership at theregional level is a key factor for system development. Supportive
leadership not only ensures the availability of the right type andamount of resources for the system but also effects a positivechange in the culture and mindset across the general publicwith regards to bystander duties. Furthermore, the push forfair policies and standards supports employee motivation andretaining citizens’ faith in the system.

Technology and infrastructure
Technology plays an important role in ensuring the timely
delivery of services and improving efficiency across the chainof care. Similarly, the right infrastructure is necessary toprovide pre-hospital and emergency department services. A
best-in-class system is one that adopts emerging technology
to optimize the system and ensures that ambulances andemergency departments are well-equipped and geographicallywell-distributed to efficiently provision emergency services.

Coordination and integration
In a typical continuum of care, emergency care starts withbystander response and ends when the patient is discharged
from the hospital. Coordination among the various stakeholders
involved in the delivery of care ensures high-quality care.
Integrating IT systems across the chain of survival positively
influences these coordination efforts.

Performance monitoring and continuous improvement
Key performance indicators must be set for quality as wellas performance to ensure effective emergency care service
delivery. To ensure there is no conflict of interest, the body thatdefines standards and audits and regulates performance should
be different from the body that provides services. Continuous
monitoring and performance management are necessary toensure that the system is improved periodically and that a
consistently high level of care is provided across the entire
system.

13

Notes14

Contacts
If you would like more information or to arrange an informal discussion on the issues raised here andhow they affect your business, please contact:

Austria
Bela Viragvirag.bela@adlittle.com

Japan
Ryo Hanamura
hanamura.ryo@adlittle.com

Singapore
Maki Kurosawa
kurosawa.maki@adlittle.com

Belgium
Vincent Bamberger
bamberger.vincent@adlittle.com

Korea
Kevin Lee
lee.kevin@adlittle.com

Spain
Carlos Mira
mira.carlos@adlittle.com

China
Ryo Hanamura
hanamura.ryo@adlittle.com

Latin America
Rodolfo Guzman
guzman.rodolfo@adlittle.com

SwedenUlrica Sehlstedt
sehlstedt.ulrica@adlittle.com

Czech Republic
Jiri Steif
steif.jiri@adlittle.com

Middle East
Vikas Kharbanda
kharbanda.vikas@adlittle.com

Switzerland
Franziska Thomas
thomas.franziska@adlittle.com

FranceVincent Bamberger
bamberger.vincent@adlittle.com

The Netherlands
Martijn Eikelenboom
eikelenboom.martijn@adlittle.com

TurkeyCoskun Baban
baban.coskun@adlittle.com

Germany
Franziska Thomas
thomas.franziska@adlittle.com

NorwayUlrica Sehlstedt
sehlstedt.ulrica@adlittle.com

UK
Ben Enejo
enejo.ben@adlittle.com

India
Vikas Kharbanda
kharbanda.vikas@adlittle.com

PolandPiotr Baranowski
baranowski.piotr@adlittle.com

USA
Craig Wylie
wylie.craig@adlittle.com

Italy
Mario Nico
nico.mario@adlittle.com

Russian Federation
Alexander Ovanesov
ovanesov.alexander@adlittle.com

Building the next generation of emergency
care systems
Ensuring health systems have the right building
blocks to develop effective emergency caresystems for the future

Arthur D. Little
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