On January 26, 2015, the Ministry of Health and Welfare reorganized existing emergency medical care based on urban centers rather than municipalities. The Ministry also announced preliminary public notification of the provisions of the partial amendment to the Enforcement Regulations of the Act of Emergency Medical Care, which was intended for the designation of additional urban centers for emergency medical care [1]. The principal provisions of this amendment notification are to provide active emergency medical care services by designating additional urban centers for emergency medical care. These provisions also mandate five or more emergency medicine (EM) specialists, such that at least one specialist is present in the emergency department at all times in order to improve emergency patient survival rates [1]. This mandate reflects the reality of increasing utilization of emergency departments, which have unlimited outpatient service hours and relatively high accessibility. During the medical professional labor strike in June 2000, specialists were temporarily in charge of primary care for patients visiting emergency departments. Thereafter, some reports showed encouraging results of primary care medical services provided by specialists in charge of emergency departments [2-4], which resulted in reduced use of unnecessary patient tests based on the specialists’ (1) abundant experience, (2) knowledge, (3) duration of care making admission decisions for patients, and (4) amicable mutual collaboration with other departments. This resulted in decreased duration of emergency department stays as well as reduced rates of non-emergency patient admissions. A comprehensive survey of EM specialists conducted in 2010 predicted that a total of 1,505 to 2,270 EM specialists would be necessary in order to have at least one EM specialist to care for all patients visiting each emergency department per each working hour [4-6]. However, a total of 1,211 board-certified EM specialists are reportedly working in EDs in 2015. This number is insufficient for the number of patients visiting emergency departments in Korea [4]. In an effort to investigate the most efficient measures to utilize the limited number of EM specialists, this study divided patients who visited the emergency department of a tertiary care general hospital into two groups: the SS group, in which patients were supervised by an EM specialist; and the SOC group, in which patients were supervised by an EM resident with an EM specialist on call. Differences in mortality rates by severity and duration of stay in the emergency department were compared between these two groups. This analysis may help in establishing the duty and the role of EM specialists and inform relevant policy making.

Medical care of patients visiting emergency departments has traditionally been the territory of relatively inexperienced medical interns in Korea. Interns are typically supervised by residents or specialists, linking through inter-disciplinary consultations as required [7,8].

However, primary examinations and diagnoses performed by relatively inexperienced doctors may result in delays in timely and proper treatment of patients requiring urgent management. This delay may result in disputes with patients and guardians regarding medical expenses and increased length of stay for unnecessary tests. The number of patients visiting emergency departments has increased 6% every year, reflecting the increasing role and importance of medical services offered by emergency departments. Annually, about 150 EM specialists are board-certified, but these numbers are not enough to meet the rising demand due to increasing numbers of patients. Thus, to reduce length of stay for patients visiting the emergency department and increase satisfaction, there is an increasing demand for EM specialists in emergency departments to provide rational and professional emergency care. During the nationwide doctors’ strike regarding the separation of prescribing and dispensing of drugs in 2000, specialists provided round-the-clock medical services in hospital emergency departments for approximately six months. The services provided by specialists in the emergency department relatively decreased patient length of stay while not negatively affecting mortality rates. The specialists reduced the number of unnecessary tests and increased patient satisfaction, as reported by various studies [2,3,9]. Furthermore, an acuity scale tool was used to triage patients and provide rational management of emergency departments [10]. Medical services provided by EM specialists to patients with mildly severe conditions decreased waiting time and length of stay in emergency departments compared to groups without EM specialists. The medical services provided by EM specialists also increased patient satisfaction [11-13]. The current study divided subjects into two groups: the SS group, in which an EM specialist supervised patients’ medical care; the SOC group, in which an EM resident supervised medical care with an EM specialist on call, in order to perform comparative analyses. There was a difference in clinical outcome and acuity scale between the two groups. The number of patients with mildly severe conditions (levels 4 and 5) was greater between 5 p.m. and 9 a.m. of the next day, when one or more EM specialists provided emergency services, as opposed to 9 a.m. to 5 p.m. when four or more EM specialists were available to render services. Thus, this observation was expected as a result of increased numbers of discharge cases as determined by clinical outcome. The rate of consultation requests from on-call physicians in the department of internal medicine was highest in the SS group, while the rate was highest for EM physicians in the SOC group. The high consult rate was affected by patients transferred from the outpatient department of internal medicine who were admitted to the hospital through the emergency department during the regular hours, when four or more EM specialists were available. Patients may be admitted through the hospital, clinics, and outpatient departments during regular hours. Thus, the proportion of patients with mildly severe conditions was relatively lower in the department of EM. Moreover, the duration of stay in the emergency department and the length of time to request consult from other departments relatively increased when an EM specialist was involved with the clinical decisions. The number of tests performed and the length of stay increased in the emergency department in order to provide accurate diagnosis and treatment; additional tests such as computed tomography or magnetic resonance imaging might be delayed in overcrowded emergency departments. Patient care performed by an EM specialist leads to such results. However, it is difficult to make simple comparisons, since other factors such as differences in the numbers of patients cared for by EM specialists and EM residents, differences in available tests depending on the time of day, and differences in length of time required to perform duties other than medical services.

Relative to the length of stay, the mortality rate was significantly lower in the group of patients with severe-to-moderate conditions (levels 1 to 3) supervised by an EM specialist who made clinical decisions.

Efficient utilization of manpower is possible by assigning the relatively limited number of EM specialists to supervise patients with severe-to-moderate illness (levels 1 to 3, the group with the highest mortality rates), while senior EM residents supervise patients with mild illness (levels 4 and 5), with an EM specialist on call as needed.

This study has several limitations. First, we analyzed data from a single tertiary-care general hospital. Thus, the findings may not be applicable to other institutions since the work conditions, intensity, and EM specialist hours differ at each hospital. Second, because the patients were classified into groups based on the working hours of EM specialists, various intervening factors, including differences between day and night shifts, types of applicable tests, and supportive divisions, could also have affected the observed results. However, these factors likely had a limited effect on the results of this study due to (1) the nature of EDs, in which emergency medical services are provided 24 hours a day, seven days a week, and (2) there was no difference in the severity rates of patients between the two groups. Further prospective, multicentered studies could better elucidate the role of EM specialists in the ED. Third, the retrospective study of this investigation prevented assessment of the effects of the clinical decisions and care provided by EM specialists on the qualitative aspects of medical care, such as fairness of medical services, patient satisfaction, etc., in addition to patient survival rates.

In summary, the results of this study suggest that the most efficient utilization of the limited manpower of EM specialists requires that they care for patients with severe-to-moderate illness (levels 1 to 3). While this change would increase the average duration of ED stay, it could significantly lower in-hospital mortality risks. This study demonstrates the improved efficiency of utilizing EM residents rather than EM specialists to supervise patients with mild illness (levels 4 and 5) due to increased manpower, connectivity with other departments, and utilization of training physicians (interns).