Integrating India’s Emergency Response: A Health System Priority

India experiences millions of time-sensitive medical emergencies every year, where each minute is critical. Emergencies trigger a race against time, a ‘golden hour’ during which a quick response can mean the difference between life and death. In 2022 alone, over 0.43 million Indians died due to unintentional injuries, nearly half from road traffic accidents, among other diverse complications.

Different states and providers run their ambulance fleets and call centres without unified protocols, with differing emergency contact numbers. The lack of a single, unified ambulance and Emergency Department (ED) system means patients often bounce between providers. Referral confusion is common, especially between smaller private facilities and larger public hospitals. Private nursing homes often attempt to treat critical patients beyond their capabilities, causing delays in transfers to appropriate facilities. This breakdown in referral systems leaves ambulances shuttling patients around, scrambling for an Intensive Care Unit (ICU) bed. By the time a critically ill patient reaches a well-equipped centre, it may already be too late for definitive care. Fragmentation, thus, impedes the healthcare industry/care, introducing unnecessary delays and errors, necessitating an integrated approach.

The lack of a single, unified ambulance and Emergency Department (ED) system means patients often bounce between providers.

System Under Pressure

India’s prehospital emergency system faces gaps in ambulance availability, response times, and trained staff. The National Health Mission (NHM) fleet of ambulances has about 15,283 Basic Life Support (BLS) ambulances. This translates to an average response time of 10-25 minutes. Much of this problem stems from a lack of well-trained Emergency Medical Technicians (EMTs). 

India's prehospital system as a whole is underdeveloped: too few vehicles, too few personnel, and poor technology integration. Consequently, citizens do not call ambulances, and serious cases utilise means other than EMS to reach hospitals, reflecting low awareness and confidence in these services.

Hospital EDs are equally stressed, where many lack essentials such as a dedicated trauma operating theatre (OT), unloading space for ambulances, or point-of-care (POC) lab facilities. Many government hospitals lack essential resuscitation drugs and equipment needed for emergency care. Additionally, emergency beds on average constitute 3-5 percent of total hospital beds despite 18-40 percent of hospital admissions coming through emergencies. Many facilities also lack standardised triage systems and standard operating protocols (SOPs) for time-critical conditions, leading to inconsistencies. Manpower shortages, particularly among emergency medicine physicians and trauma specialists, specifically in rural and semi-urban regions, compound the prevalent challenges. Inept doctors or medical officers are the ones manning most EDs as speciality training continues to be in its infancy stage (officially recognised only in 2009 in India).

There is no transfer policy facilitating smooth diversions of stable patients from busy government hospitals to private facilities, nor a mechanism for private hospitals to alert public advanced trauma teams when necessary. 

These gaps are further exacerbated by the public and private sector segregation. The government hospitals, which receive most of the emergency referrals, are overwhelmed. Private hospitals with spare capacity are not well-integrated into the emergency referral system. There is no transfer policy facilitating smooth diversions of stable patients from busy government hospitals to private facilities, nor a mechanism for private hospitals to alert public advanced trauma teams when necessary. 

Countries with advanced emergency systems, such as the United Kingdom (UK), use a hub-and-spoke model. The UK National Health Service introduced regional ‘Major Trauma’ Networks in 2012, providing dedicated trauma centres and official referral paths. In five years, critically injured patients had a near 19 percent increase in survival chances, resulting in lives saved by optimised care and direct transport to big centres. This hub-and-spoke system also resulted in reduced hospital stays and improved recovery rates. Advanced EMS systems of countries such as Australia or the United States (US) employ universal emergency numbers (911/000), exceedingly well-trained paramedics under the auspices of protocols, and immediate communication for addressing all casualties under a single umbrella.

A Roadmap for Integration

India needs a roadmap to turn its fragmented emergency response into an effectively functioning machine. Problems with funding for expansions, imparting large-scale training, and coordination in India's federal governance structure and hybrid health system need to be addressed. This requires political will and an understanding that emergency care is an investment. The main strategies involve:

• Integrated Emergency Helpline and Dispatch: A single and easy-to-remember emergency number can be subscribed to for the whole country and backed by a nationwide network of call centres, where all emergency calls can be directed, clarifying service contact. Tele-consultant physicians and trained emergency dispatchers can be used to vet the calls, give first-aid instructions, and send off the closest suitable ambulance, optimising case assignment depending on severity. The system can also employ Global Positioning System (GPS)-equipped ambulances for smart dispatch and traffic routing, improving response times.

• Ambulance Fleet and EMT Training: Ambulance capacity must be augmented, aligned with international standards, with each vehicle duly manned and equipped. Human resource investment may be directed towards ramping up EMT training courses, leveraging public-private partnerships (PPPs) with accredited institutions. Additional training modules for current EMTs may also be created, along with career development incentives to retain experienced professionals.

• EDs in District Hospitals: Each district hospital ED should be fully staffed and properly equipped to handle a variety of severe cases. This includes having special triage areas to prioritise patients, ambulance bays for quick transfer, and allowing round-the-clock use of key diagnostic equipment. Uniform SOPs for the handling of frequent emergencies could be adopted with strict timelines. General physician and nursing courses on emergency care algorithms could help improve the quality of care. Furthermore, infrastructural investments should aim for increasing emergency bed utilisation and designating step-down observation units.

• Trauma Hubs and Hub-and-Spoke Linkages: A tiered system based on a hub-and-spoke model can be formed with medical college hospitals or regional centres as specialised hubs for trauma and emergency care. Such hubs can be endowed with high-level facilities and can provide backup to clusters of smaller hospitals in their catchment areas. Referral relationships may be institutionalised through which small hospitals (spokes) refer complicated or critical cases to the hubs according to set criteria, and the hubs offer teleconsultation services to the spokes. This would also necessitate creating standardised transfer protocols, such as provision for safe transfer of patients and the utilisation of dedicated critical care ambulances for transfer between facilities. 

• Command and Teleconsultation Centres: The system could be supported by 24X7 state or regional command centres with emergency physicians, communications specialists, and technical staff to monitor emergency response activities. Digital dashboards could be used to track ambulance locations, hospital bed availability, and emergency calls across regions. With telemedicine connections, the command centres would be able to provide immediate medical advice to field EMTs.

• Governance and Quality Monitoring: Successful integration of emergency care systems relies on strong governance structures. Clear standards of emergency response can be set and continually monitored. A state or central authority can be assigned to monitor Key Performance Indicators (KPIs), utilising the data to continuously improve quality. Regulatory frameworks can also mandate private hospitals to accept emergency cases and stabilise patients before referring them, in line with the existing legal provisions. 

• Public Awareness and Bystander Involvement: An integrated emergency care system could only be as good as its first Point of Contact (POC), which is the public. High-level, long-term public education campaigns could be employed to inform citizens about recognising emergencies and responding appropriately. Public participation in the face of emergencies can revolutionise survival opportunities, for example, Cardiopulmonary Resuscitation (CPR) training through school courses, corporate health training, and community education for heart attack or cardiac arrest. Currently, India's bystander CPR rate is between 1.3 percent and 9.8 percent, compared to the 40–60 percent in most high-income nations, and under 2 percent of adults have received formal CPR training. Early intervention has been proven to double the survival rate with cardiac arrest. Educational public programmes would further emphasise educating citizens regarding the use of the emergency call system.

 An integrated emergency network must be on the national agenda, linking all the elements— ambulances, primary health centres, private nursing homes, government hospitals, speciality institutes— as one continuum of care. If well-executed, India's emergency care system could potentially save thousands of lives annually.

K. S. Uplabdh Gopal is an Associate Fellow with the Health Initiative at the Observer Research Foundation.

Nimisha Chadha is a Research Assistant with the Health Initiative at the Observer Research Foundation.

• Healthcare
• India
• coordinated emergency care framework
• emergency care in india
• integrated emergency care network
• integrated emergency care network in india
• integrated emergency network
• integrated system of emergency care

The views expressed above belong to the author(s). ORF research and analyses now available on Telegram! Click here to access our curated content — blogs, longforms and interviews.

PREV NEXT