176｜Practice

Addressing issues associated with prehospitalemergency transportation
1. Background and goals
We all take advantage of the 119 emergency ambulance services in the event of unexpected injury oracute illness. In Tokyo, it takes as much as 6 min 38 sec on average (as of 2012) for an ambulance toarrive on scene after mobilization. Moreover, on-scene time continues to increase every year, potentiallydelaying treatment of high acuity illness, such as cardiovascular diseases and stroke, and causing permanent damage or serious complications. These issues may turn rescue activities that would have saved
lives into fatalities.
Although various factors, including patient- and community-specific factors and changes in socialstructures, are involved in prolonging on-scene time, no previous study has examined the entire range
of factors at once, making it difficult to address the problem. Cities that provide broad-based criticalcare activities in densely populated areas, such as the Tokyo and Osaka metropolitan areas, are likely toface problems associated with longer emergency service time, whereas Fukuoka City and other smaller
cities tend to provide critical care activities smoothly within a given area.
The aims of this study are (1) to reveal issues associated with prehospital ambulance transportationby using objective floating car data on ambulance transportation to develop effective measures and (2)to investigate the case where injured or diseased patients are transported from hospital to hospital due
to each one refusing to accept them by comparing differences in emergency care services between cities
with and without such problems. Findings from these studies will allow us to recommend solutions toperforming effective prehospital critical care activities in much broader areas in the future.

2. Research content
2-1. Comparisons of critical care activities among cities of different sizes
To reveal the differences in critical care activities among cities of different sizes, we analyzed actual care
activities provided in Tokyo , Fukuoka City, Fukuoka Prefecture, and Kamagaya City, Chiba Prefecture(Fig. 1). Although the size of Fukuoka City is somewhere between that of Tokyo and Kamagaya City,
individual emergency response teams in Fukuoka City are responsible for a larger population and awider area. Travel time between dispatch and arrival on scene was shortest with Kamagaya City. However, Fukuoka City had the shortest on-scene time, which was 6 min 25 sec shorter than on-scene time
Project Leader: Takashi Moriya
Professor, Emergency Department, Saitama Medical Center, Jichi Medical University

Addressing issues associated with prehospital emergency transportation｜177

Returning tothe station

7’23

Patient handover
to hospital

11’08

6’06

Arrival at
hospital

Transportation

Arrival on scene

Dispatch

Receipt of callFukuoka City(1’08)

30 min(target time)

13’15

27’1165’03

Reference: Fukuokashi shobo nenpo heisei 18 nen [Fire-Fighting Annual Report 2006], General Affairs Division, Fukuoka Fire Prevention Bureau

27’06

7’06

Returning tothe station

3’30 13’36

Patient handover
to hospital

Arrival at
hospital

Transportation

Arrival on scene

Dispatch

Receipt of callKamagaya City(1’35)

16’30

67’48
Emergency activity record collected between November 2004–February 2005, and floating car data collected between November 2004–February 2005

9’39

26’26

Returning to
the station

17’33

Patient handover
to hospital

Arrival at
hospital

Transportation

Arrival on scene

DispatchReceipt of callTokyo

6’1018’58

78’45
Reference: Heisei 18 nen kyukyu katsudo no gaiyo [Outlines of Emergency Activities in 2006], Emergency Management DivisionFigure 1. Comparisons of current critical care activities provided in Fukuoka City, Kamagaya City, and Tokyo
The target time between dispatch and arrival at hospital is 30 min.

required in Tokyo. Tokyo also had the longest transportation time.
2-2. Current situations in critical care activity provided to high acuity patients duringtransportation
Analysis of emergency care service data collected at the Critical Care Center of Nihon University Itabashi Hospital,(1) Tokyo, revealed that (1) transportation time is excessively long in certain areas, (2)rapid transportation is prevented by narrow streets and railroad crossings where gates remain lowered
for an extended time, and (3) there are only a small number of secondary emergency care facilities
equipped and designated for providing care to moderate acuity patients in Tokyo. This results in patients
having to be transported to tertiary emergency care medical facilities, which provide care to high acuity
patients requiring admission to an intensive care unit, because their conditions deteriorated while the(1) The Critical Care Center of Nihon University Itabashi Hospital is a tertiary emergency care facility for treating patients facing criticalsituations. Patients in less serious condition, but who still require inpatient treatment or emergency surgery, are treated at secondary
emergency care medical facilities.

178｜Practice

The distance between tertiary emergency care medical
facilities is relatively far in Western Tokyo
Transported to Nihon University Itabashi Hospital ispreceded because transportation time is easily predicted

National Defense Medical
College Hospital
Approximately 14.0 km

Western Tokyo

Itabashi Ward

Teikyo University
Hospital

Use of the expressway
is necessary

emergency response teams
were traveling from hospital tohospital in search of an appropriate destination (Fig. 2).

Kita Ward

Approximately 10.5 km

Showa General
Hospital Approximately 8.5 km

KodairaCityNerima Ward

Nihon University
Itabashi Hospital

Approximately 8.5 km

Toshima Ward

Railroad crossings and other traffic
factors may affect transportation time

Nakano Ward
Musashino City Approximately 6.5 km
Suginami Ward
Tertiary emergency care

Japanese Red Cross Musashino Hospital

medical facilities

The distance to a tertiary emergency care facility is a straight distance from Shakujii Park, which is located almost mid-way between the Oizumi and Shakujii districts.

Figure 2. Problems associated with the area covered by individual tertiary
emergency care medical facilities

2-3. Example of cities that operate a smooth emergency care system
In contrast, some cities provide efficient emergency care services. For example, Fukuoka City utilizes a
Global Positioning System to locate an emergency response team, which displays the address to shorten
the time to locate the scene,
FAST: a system used to control traffic signals to prioritize an approaching ambulance
utilizes information on trafficand other emergency vehicles and to prevent traffic accidents involving thosevehicles at intersections.
and hospitals’ preparedness to
Development of the standard FAST system
accept emergency patients, andrelocates emergency response
teams if they are unevenly distributed in a given area toreduce travel time, on-scenetime, and transportation time.
Kanazawa City has incorporated a traffic signal preemption system for emergency
vehicles (Fast Emergency Vehicle Preemption System (FAST))
to streamline the city’s emergency services (Fig. 3). In the

Medical institution

Improvement of patient survival rate due to rapid transportation

Optical beacon

Firedepartment

Traffic control center

Accident prevention

Preemption of
traffic signals
Traffic signal preemption
to extend green lights or
shorten red lights foremergency vehicles

Optical beacon
Optical beacon

Scene of the accident
Reference: Shobo no ugoki [Current Developments in Fire and Disaster Management], No. 440, Fire and Disaster Management Agency, November 2007

Figure 3. Fast Emergency Vehicle Preemption Systems (FAST) inKanazawa Cityareas where the FAST system isin place, the speed of emergency vehicles has been improved, travel and transportation time has beenshortened, and the emergency service area covered by each response team has been expanded.

国際交通安全学会ハン��ックe150213入稿用.indd 178

15.2.17 1:23:35 PM

Addressing issues associated with prehospital emergency transportation｜179

3. Conclusions
A close association between fire departments, on-scene emergency response teams, and hospitals is thekey to proper critical care activities. To improve the rate of life-saving emergency services, it is of paramount importance to shorten and tighten the links between the three divisions in the critical care triangle (Fig. 4). This can be achieved by shortening time for travel, on-scene prehospital care, and transportation. In search of solutions, we investigated the current situations and challenges of critical care
activities provided in three cities.

Arriving
on scene•Deciding route•Continuing observation

Emergency
scene Leaving
scene•Patient handover to hospital;
reporting to physician about
patient’s condition,
prehospital care provided,and observation in ambulance•Submission of a patientdelivery confirmation form

•Deciding routeionmet
rtaspotim

lishment of a proper emergency management system or

On-scene timenTra

to locate the scene and toarrive on scene can be effectively shortened by the estab-•Assessment and prehospitalcare by emergency response team
•Determination of a destination
hospital

iving ti

The findings of this study
showed that the time required

Arreby the incorporation of FAST,
and that emergency transport
Dispatch
Arriving
at hospitaltime can be reduced by approFire
Receipt ofLeaving
Arriving at
Return time hospitalemergency
Hospitalfire station
department
call
priately placing regional secPatient handover
Waiting for•Identification of scene emergency call
•Returning to fire station time at hospital
ondary emergency medical•Preparation ofambulance
facilities. Successful criticalFigure 4. Critical care triangle
care activities cannot be
achieved only by establishing
information systems or by streamlining emergency hospitals. It is important to develop a critical caresystem that is appropriate for the size of each community to build close working relationships and foster
highly sophisticated collaboration between emergency management centers, emergency response teams,and physicians.
Issues that need to be addressed include the incorporation of the command and control system, theinvestigation of effective wide-based emergency services, and the determination of how the FAST system would improve emergency transportation. Furthermore, it is important to develop measures in theevent of hospitals’ refusal to accept emergency patients in order to improve hospital acceptance rates.

4. Future outlook
The prolongation of time required for emergency care response and transportation is a serious problem
even in local cities. On-scene time is also anticipated to increase due to the expansion of prehospitalcare. It is therefore important to establish an effective multidisciplinary cooperation system between
physicians, nurses, administrators, the police, the fire department, emergency services, and thegovernment.