ABSTRACT

Introduction:

This report aims to illustrate the history and current status of Japanese emergency medical services (EMS), including development of the specialty and characteristics adapted from the U.S. and European models. In addition, recommendations are made for improvement of the current systems.

Methods:

Government reports and academic papers were reviewed, along with the collective experiences of the authors. Literature searches were performed in PubMed (English) and Ichushi (Japanese), using keywords such as emergency medicine and pre-hospital care. More recent and peer-reviewed articles were given priority in the selection process.

Results:

The pre-hospital care system in Japan has developed as a mixture of U.S. and European systems. Other countries undergoing economic and industrial development similar to Japan may benefit from emulating the Japanese EMS model.

Conclusion:

Japan has the potential to enhance its current pre-hospital care system, but this will require greater collaboration between physicians and paramedics, increased paramedic scope of medical practice, and greater Japanese societal recognition and support of paramedics.

Japanese Emergency Service System and its History

The existing system for emergency medical services in Japan depends on two distinct entities: the fire department, which is responsible for transporting patients, and the emergency medical system, which is responsible for actual medical care.

Emergency transport service in Japan is mostly performed by the fire department in each local government district/locale. Although not originally a responsibility of the fire department, emergency transport service has been performed by local fire stations since 1986, when it became required by national law.⁴ As a natural extension, pre-hospital care is considered a major responsibility of local government.

Japanese emergency medical service is based on two national systems: the emergency notification system, which began in 1964, and a supplementary system, which began in 1977. A partial amendment of the Fire Protection Law of 1986 states: “Patients with life threatening conditions and/or with disease that has possibility of severe worsening, and without any method of appropriately transporting [themselves] immediately to places such as medical facilities are the subjects of emergency medical services.” This amendment established and legally acknowledged emergency transport as the responsibility of fire departments in the modern system of emergency medical service in Japan. Of note, this service was intended for transportation, and not for pre-hospital medical care.

In December 1997, based on the report from the Emergency Medical Service System Basic Problem Commission, the national emergency medical system (Figure 1) was established.⁵ This system has three layers of service: the primary, secondary, and tertiary emergency medical systems (Table 1). The primary emergency medical system provides what is commonly called primary (or basic) medical care. These medical facilities are often the first point of contact for patients in the system and are responsible for handling relatively mild cases. At the end of 2003, 509 holiday and night-time urgent care centers were operating, and 686 areas with on-call private practitioners were registered.

The secondary emergency medical system is the focus of Japan’s emergency medical services; it provides care to patients who need hospitalization or emergency surgery. Emergency notification hospitals, national or private hospitals (both single-specialty and general hospitals), occupational health hospitals, university hospitals, and medical association hospitals comprise this system. Hospitals in various regions take turns providing such emergency medical services. However, in areas that have adequate medical resources (i.e., Tokyo), certain hospitals are permanently assigned to provide secondary emergency medical services as part of the holiday and night-time medical services of local governments. In areas where hospitals take turns providing secondary emergency medical services, pre-hospital transport times may vary widely based on the hospital’s location, and hospitals with fewer resources may be overwhelmed when they are “on duty.”

The tertiary emergency medical system provides 24-hour care for patients with serious and potentially fatal conditions such as cerebrovascular events, cardiac events, and severe injuries. The highest level of medical care is provided in this system, which is supported by specialists and supervisory physicians of the Japanese Association for Acute Medicine.

In response to the 2000 Ministry of Welfare report on pre-hospital care and rescue commission, emergency medical care centers were positioned as regional centers for pre-hospital care at the local level. They were expected to establish medical control systems and provide local paramedics with instruction, guidance, and post-event evaluations. By November 2004, there were 173 emergency medical care centers throughout Japan, and new small-scale centers called “mini ERs” are planned for each secondary emergency medical system district.⁶

An important issue that has arisen is the wide variability in quality of care between populous and financially -stable major cities (such as Tokyo) and rural regions. While major cities can meet most of the criteria for establishing emergency departments (EDs) in hospitals, many of the regional hospitals have not yet met official standards. Many hospitals have been forced to quickly establish EDs in response to government calls for increased emergency facilities.⁷ According to a survey conducted in Fukuoka prefecture, only four of 28 hospitals were certified by the Japanese Association of Acute Medicine, and only nine had certified acute care physicians.⁸ Fukuoka has a population of 1.32 million (2005) and is considered one of Japan’s large cities; however, the staffing in its hospitals was found to be inadequate. The researchers who conducted this study concluded that many Japanese EDs were seriously understaffed, even in large cities.

Another fundamental issue is the absolute shortage of both medical personnel and available hospital beds. Ambulances may travel long distances (mean transport time in 2006 was 57 minutes⁹) to reach an appropriate or designated hospital but may not find a readily available hospital bed. In 2007 two similar incidents in the Nara prefecture captured national attention because ambulances transporting pregnant women in critical condition were unable to find hospital EDs with available beds and qualified physicians. ^10,11 These incidents prompted improvement in communication between local hospitals and emergency dispatchers, and led to increases in hospital staff with obstetric-specific training.¹²

The Role and Issues of Paramedics in Japan

In 1991 Japan officially established the role of the paramedic and enacted related regulations, designating its workers as medical professionals and establishing that emergency medical services encompasses both medical care at the scene and transport to medical facilities.¹ Paramedics are nationally licensed, not as part of the certification within fire departments, but as a new medical profession in its own right.

The U.S. has highly trained paramedics that provide high-level emergency medical care. One difference between paramedics in the U.S. and Japan is the amount of training required. In the U.S. the classification, Emergency Medical Technician (EMT)-Paramedic, indicates that the individual has taken approximately 1200 hours of required coursework and training.¹³ The EMT-Paramedic National Standard Curriculum recommends 500–600 hours of classroom/practical laboratory, 250–300 hours of clinical training, and 250–300 hours of field internship.¹⁴ In Japan, most paramedics have a firefighter background. The paramedic job requirements include a minimum of five years of employment as ambulance personnel, approximately 509 hours of lecture, and 406 hours of hospital training or simulation in a designated training facility. This represents a total of approximately 915 hours of training; however, on-the-job training with currently certified paramedics is not required.¹⁵ In addition, there is no system for relicensing or renewal in Japan, and continuing education is up to each individual.

Another difference between the U.S. and Japanese paramedic profession is that most Japanese paramedics belong to the department as public civil servants and only a minority work as paramedics for private entities. U.S. paramedics may be either civil servants or private citizens. Patients in the U.S. are responsible for the costs associated with pre-hospital care, which forms much of the business of emergency medical services. Calling for an ambulance for minor conditions or when transportation to the hospital is unavailable occurs routinely in Japan but infrequently in the U.S.

Doctor Car Service

France utilizes a different EMS system in which traditionally hospital-based medical providers such as physicians may provide care outside of the hospital.¹⁶ The French system, called “SAMU,” evolved because French physicians felt they were most qualified to perform resuscitation procedures in the pre-hospital setting. Pre-hospital medical professionals, including physicians, initiate medical care at the site of the incident. The system is nationally organized by the Ministry of Health of the French government. Although commonly referred to as a “Doctor Car,” the arriving medical team may not include a physician, especially for cases deemed not life-threatening. This system is independent of the fire safety service and emphasizes the independence of EMS. France, Germany, and Italy have the most established system of sending doctors in ambulances.¹⁷

In April 1991 the Japanese Lower House Social and Labor Commission Conference Minutes emphasized the introduction of “European styles of paramedic systems that routinely send physicians to the site of incident,” and encouraged the evaluation of a SAMU-like system.¹⁶ In Japan, doctor cars can operate in three different ways. The first is the “docking method,” which is used in the Aizu and Osaka Emergency and Life-Support Centers.¹⁸ When an emergency call is received, an ambulance is dispatched from the fire department and a doctor car is dispatched from a hospital; the two meet on the way to arrive together at the event site. The second is the “rendezvous method,” in which the two arrive separately at the event site. The last method is the “Funabashi System,” which was adopted by the city of Funabashi and permanently stations a doctor car in the fire house through the support of the local medical association. As an extension to this doctor car service, the Congresses passed the helicopter service law in June 2007, as a result of the success of introducing helicopters in nine base hospitals throughout Japan. The law was passed partly in response to the current shortage of physicians, especially in rural areas.¹⁶

Supporting Others in the Process of Development

Although the Japanese system is still evolving, not having yet achieved maximal efficiency or quality of care, Japan has been a leader in assisting other nations with the process of developing their emergency medical systems. One of the most notable efforts has been in Vietnam, where the Japan International Cooperation Agency has provided cars for use as ambulances as well as other emergency equipment since 1994.¹⁹ Because of increases in the number of victims from road traffic accidents in major Vietnamese cities, the lack of an adequate EMS system has became a serious issue. Japan has experienced similar issues in its process of economic and industrial development. Japanese emergency care professionals are assisting the Vietnamese in strengthening their “115” system and are encouraging the development of Vietnamese emergency care professionals.