Project Title

An Implementation Research Study on Developing a High-Quality Patient-Centric Integrated Model for Emergency Care System in Selected Districts of India

Program Officer

Dr. Joy Kumar Chakma | Scientist F & Head Central Procurement Cell (CPC)

NHRP Area

Acute Emergency Care

Project Status

Ongoing

Date of Start

January 2024

Duration

36 months

  • Summary

  • Acute emergency care is a critical component of the health systems that drastically improve the outcomes of time-sensitive emergencies. Majority of early deaths from such time-sensitive conditions are the result of inadequate pre-hospital care, unavailability of transport, or both. In India, emergency care system is fragmented and inefficient leading to care delays and suboptimal patient outcomes. At present, large-scale implementation research, using an integrated approach to develop a scalable patient-centric emergency care system, remains sparse in India. Implementation research is crucial to understand the contextual factors that promote or hinder transformation from low-quality to high-quality emergency systems. This study aims to develop and evaluate a patient-centric, high-quality integrated emergency care system model in selected districts of India.
  • The INDIA-EMS project is an implementation research study of mixed methods design undertaken in selected districts of the states of Punjab (Ludhiana), Gujarat (Vadodara), Madhya Pradesh (Vidisha), Odisha (Puri) and Puducherry. Eight priority time sensitive emergencies such as trauma & burns, STEMI, Stroke, Poisoning, Snakebite, Acute Respiratory Illness, Maternal and Neonatal emergencies are targeted in this project. This project is based on a hub and spoke model with the tertiary care facility (public/private) acting as the hub while the secondary and primary public health facilities act as spokes. This model would span community, pre hospital ambulance, different healthcare facilities and would be interconnected through effective communication, transportation, and both referral and counter-referral systems. The formative research includes baseline facility and ambulance assessments, community survey to identify gaps that help in developing the initial model (M0) of integrated emergency. The model is optimized using qualitative research and outcome indicators through three iterative cycles designed as a continuum of care pathway that encompasses the community, through pre-hospital, to various levels of healthcare facilities. A total of three iterative processes will be done to refine the model and to develop the final model(M3).The final high quality integrated emergency care model will be scaled up in consultation with the State government and its population coverage will be evaluated at the end line.
  • Ethics approval was obtained in all the project sites. The trial is registered with CTRI (Clinical Trial Registry of India; CTRI/2024/01/061304).

  • Public Health Relevance

  • Time sensitive emergencies warrant immediate and time-bound care to prevent related morbidities and mortalities. This project focuses on developing improved emergency care systems which is accessible to all with a seamless continuum of care pathway, enabling timely definitive treatment at appropriate facilities thereby significantly reducing morbidity and mortality associated with the eight priority time sensitive emergencies.

  • Problem Statement

  • Globally, emergency medical diseases (EMDs) pose a significant public health problem, accounting for approximately 28.3 million deaths annually. South-East Asia bears a notably high burden, with 90% of deaths and 84% of disability-adjusted life years (DALYs) attributable to emergency conditions. Ischemic heart disease, stroke, neonatal conditions, lower respiratory infections, and a combined category of injuries and road traffic accidents were the five leading EMD causes of death in India in 2019. The combined EDMR of these EMDs was 251 deaths per 100 000 population (111, 51, 32, 29 and 28.3/100,000 population respectively) in all age groups. These EMDS were thus responsible for 37.4% of all the deaths in the country. The country also has the highest absolute number of deaths (51,000) due to snakebite in the world (4/100,000 population). India with a maternal mortality rate of 6/100,000 in the age group of 15–45 years accounts for 12% of the global deaths. The leading cause of these maternal deaths were obstetrics haemorrhage (47%) and hypertensive disorders of pregnancy-eclampsia and preeclampsia (7%) in 2019. According to a 2021 study by NITI Aayog, EMD’s contribute 19-39% of hospital admissions in India. The report also revealed that the emergency care system in the country is fragmented and lacks critical resources. There is a noticeable disconnect in the care continuum, from pre-hospital settings to primary and secondary care centers, district hospitals, private institutions, and tertiary care facilities. The challenges faced by emergency care in India requires coordinated participation of the government, public health facilities, private providers, healthcare institutions, civil society and sectors outside health like transport, education and communication to develop a high-quality integrated model for emergency care. In India, the emergency services have limited community access, inadequate infrastructure, poor inter-unit coordination, personnel shortages and there is a dearth of training resources.

  • Objectives

  • Primary Objective:
    • 1. To co-develop a district-level implementation model for high-quality patient-centric integrated emergency care through iterative processes.
  • Secondary Objectives:
    • 1. To evaluate the model in terms of feasibility, acceptability, cost, and effectiveness of the implemented model to achieve emergency care preparedness and coverage.
    • 2. To disseminate the research findings and best practices at the national level and assist the state in scaling up the optimized model.

  • Project Sites

  • 1. All India Institute of Medical Sciences , Bhopal
  • 2. All India Institute of Medical Sciences , Bhubaneswar
  • 3. awaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Puducherry
  • 4. Parul Institute of Medical Sciences & Research, Parul University, Vadodara
  • 5. Christian Medical College , Ludhiana

  • Anticipated Outcomes

  • 1. The proportion of patients who were provided definitive care for the specified emergency medical condition at an appropriate health facility in a time sensitive manner.
  • 2. Implementation outcomes will be assessed based on :
  • a. Acceptability: Patient satisfaction and acceptability of health care workers (both prehospital and in hospital).
  • b. Implementation Costing: Total cost incurred for implementation of the INDIA - EMS model.
  • c. Adoption/Feasibility: Challenges faced in adopting the INDIA-EMS model by emergency care providers identified during program learning are addressed.

  • Activities

  •  
    1. 1. Developed and validated data collection tools for health facility assessment, ambulance assessment for emergency readiness, community survey, competency assessment of healthcare personnel, 24hr live observation, post care survey of patients and IDIs & FGDs.
    2. 2. Baseline assessment conducted across five districts (Ludhiana, Puducherry, Puri, Vadodara, Vidisha). Community surveys covering 29,939 households measured emergency disease burden, health-seeking behaviour, out-of-pocket expenditure, and mortality.
    3. 3. Health facility assessments of all primary health centres, community health centres, civil hospitals, sub district hospitals and district hospitals of the 5 districts evaluated for infrastructure, equipment, drugs, protocols, and staffing for emergency readiness.
    4. 4. Ambulance assessments completed for equipment availability and response capabilities.
    5. 5. Competency assessments of medical officers, nursing officers, and emergency medical technicians conducted to evaluate their clinical skills using validated tools.
    6. 6. Live observations at district hospitals recorded time-interval benchmarks (door-to-ECG, door-to-thrombolysis, door-to-CT).
    7. 7. Qualitative data from focus group discussions and in-depth interviews with healthcare providers, patients, and community members identified systemic barriers.
    8. 8. National consultation meetings and co-design sessions conducted with key stakeholders from all sites and subject experts.
    9. 9. Periodic Review cum consultation meetings conducted with district and state officials including state advisory committee, MD NHM, Health secretaries.
    10. 10. The first and second rounds of concurrent evaluations are currently underway at the study sites.
  • Community Level
    1. 1. Training of First Responders for acute medical emergencies are being undertaken at all sites.
    2. 2. Co-development and dissemination of standardized IEC materials for eight priority time-sensitive emergencies.
    3. 3. Implementation of facility-based visual communication interventions.
    4. 4. Strengthening emergency service linkage through point-of-care signage.
    5. 5. Integration of pre-hospital care awareness into Community Health Days.
    6. 6. Odisha's emergency preparedness SOP was adopted for the Rath Yatra mass gathering.
    7. 7. Low-cost CPR manikins and flipcharts developed by Ludhiana team distributed to ASHA workers.
  • Pre-hospital - Ambulance
    1. 1. Smart Ambulance Dispatch System: a Mobile application developed for 108 call operators, Emergency Medical Technicians (EMTs), and ambulance drivers.
    2. 2. Centralised Dashboard for real-time monitoring of ambulance activity and call response at the 108 Command Centre has been created.
    3. 3. 108 command centre infrastructure has been upgraded.
    4. 4. Ambulance repositioning done by geospatial mapping to identify areas of high emergency occurrence/hotspots across the district.
    5. 5. Training and Capacity Building: BLS/ALS/PHTLS Training Program for EMT's-in Pre Hospital / Enroute care
    6. 6. Need-Based Resource Allocation inside ambulances
    7. 7. Operational workflows for Pre-Hospital Care in eight priority time sensitive emergencies co-designed at National Level for eight time sensitive emergencies.
    8. 8. Collaboration with NGO volunteer support for scene care. Call location details from the incident scene are shared with the coordinator, enabling registered volunteers to reach the site and provide on-scene care.
  • Facility Level
    1. 1. Facility-level gap assessment tool developed based on IPHS standards.
    2. 2. Facility-level grading for time-sensitive emergencies undertaken in 5 districtsunder this project. Grading of PHCs, CHCs, and DHs was done based on emergency preparedness and categorised into L0, L1, L2, L3, and L4.
    3. 3. Geospatial mapping done withvisual layers created to display the distribution of health facilities, their readiness scores.
    4. 4. Establishment of triage and Strengthening of Triage processes at DH and CHCs of the districts.
    5. 5. Ensured availability of Tenecteplase to make DHH Thrombolysis ready facility.
    6. 6. Operational workflows for management of eight priority time sensitive emergencies developed for all levels of healthcare facilities.
    7. 7. Capacity building of medical officers and Nursing Officers in management of time sensitive emergencies including ECG training.
    8. 8. Co-designed Toxicology manual for management of poisoning
    9. 9. Training Manuals prepared for stroke, STEMI and Triage for Medical Officers and Nursing Officers.
    10. 10. Health workers of Government health facilities sensitised in aState-level Training of Trainers (ToT) initiative in toxicology, jointly organized by the INDIA EMS Project and the Directorate of Health and Services.
    11. 11. Dedicated WhatsApp group for emergencies such as STEMI, Snakebite and toxicology support to physicians dealing with acute management on a 24/7 basis with the trained health professionals.

  • Policy Implications & Public Health Impact

  • 1.This study will develop a scalable, high quality, patient centric model of integrated emergency care system that ensures efficient, equitable access of timely definitive emergency care at an appropriate facility for eight priority time sensitive emergencies targeting 80% population coverage in selected districts. Gaps identified in the current emergency care system are being addressed by guiding policy makers with evidence for improved resource allocation and system enhancement.
  • 2. Expanding coverage of this co-developed integrated emergency care model to 80% of the population would significantly improve timely access to life-saving interventions thereby reducing morbidity and mortality due to eight priority time sensitive emergencies.

  • Publications

  • 1. Protocol paper published in PLOS ONE · Article Source: Developing a high-quality patient-centric integrated model for emergency care system in selected districts of India: An implementation research protocol. (INDIAEMS) Ayyan S M, Kumar Singh A, S. Patadia H, Patel S, Saigal S, et al. (2025) Developing a high-quality patient-centric integrated model for emergency care system in selected districts of India: An implementation research protocol (INDIA-EMS Study). PLOS ONE 20(9): e0331290. https://doi.org/10.1371/journal.pone.0331290

  • Achievements

  • Facility Level
    1. 1. A dedicated Triage Area established at DH Puducherry, DH Puri, CHCs (Vadodara)
    2. 2. A Standardized Emergency Care Readiness Assessment (SECRA), a quantitative tool, to measure the preparedness of health facilities to manage time-sensitive emergency conditions. A comprehensive SECRA dashboard developed to display facility- level gap analysisand district-level benchmarking, enabling users to easily identify strengths and deficiencies across the emergency care pathway.
    3. 3. Operational workflows for management of eight priority time sensitive emergencies co-designed at National Level for all levels of healthcare facilities vetted by state.
    4. 4. Quick Referral Command Centreset up at Project Office, DH Vidisha for referral to tertiary care health facility in cases of STEMI, Snakebite, Poisoning and Maternal Emergencies.
  • Pre-hospital
    1. 1. The pre-hospital system at Puducherry is upgraded by developing a Smart Ambulance Dispatch System that has been internalised by the state’s 108 emergency care service.
  • Community Level
    1. 1. IEC materials for eight priority time-sensitive emergencies co-developed for risk communication and early symptom recognition, integrated with QR codes that enable real-time navigation to the nearest appropriate health facility via Google Maps vetted by the state for effective dissemination and implementation.

  • Resources

  • Media