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Introduction organize the inputs necessary for the Fragmented health system
provision of effective interventions; and services
As populations continue to grow and
(ii) as inclusive of promotion, preven-
age, there will be increasing demand for
tion, cure, rehabilitation and palliation In 2007, WHO highlighted the need to
acute curative services responsive to life-
efforts, and (iii) as oriented towards strengthen health systems, but precise
threatening emergencies, acute exacerba-
either individuals or populations.1,2 definitions and objectives, especially
tion of chronic illnesses and many routine
Acute care must also be clearly with regard to the delivery of health
health problems that nevertheless require
defined. Standard medical definitions services, often remain elusive.4 Priority
prompt action. Emergency interven-
for acuity emphasize the singular at- health problems are on consensus lists
tions and services should be integrated
tribute of time pressure. 3 Acute ser- that countries normally develop with
with primary care and public health
vices therefore include all promotive, input from international organizations.
measures to complete and strengthen
preventive, curative, rehabilitative or Health services are then oriented to-
health systems. This paper focuses on
palliative actions, whether oriented to- wards preventing and controlling these
acute care within that context. First, we
wards individuals or populations, whose priority health problems. One important
draw on standard World Health Organi-
primary purpose is to improve health component that has yet to be adequately
zation (WHO) terminology to propose
and whose effectiveness largely depends elucidated within these processes is the
working terms to define “acute care”.
on time-sensitive and, frequently, rapid influence of time on the implementation
Second, we highlight the fragmentation
intervention. and success of interventions. Preventive
of service delivery that results from not
Many individually-oriented ser- strategies primarily focus on reducing
adopting the proposed definition. Third,
vices have optimal delivery times. As the probability of incident cases through
we show the potential contribution of
a group, acute curative services are interventions that decrease the risk of
acute care to integrated health systems
the most time-sensitive, regardless developing a disease. The sooner preven-
designed to reduce all-cause morbidity
of disease entity. However, to date, tion efforts begin, the sooner incidence
and mortality. Finally, we propose key
acute care has been poorly defined falls. On the other hand, curative strate-
steps to further the development of acute
and inadequately supported in most gies reduce the probability of disability or
care that leaders, researchers and health
developing health systems. A reason- death among existing cases. The relative
workers, who are the people responsible
able working definition of acute care priority assigned to curative interven-
for maintaining strong national health
would include the most time-sensitive, tions is driven by how time-sensitive and
systems, should consider taking.
individually-oriented diagnostic and effective the interventions are, as well as
curative actions whose primary pur- by cost. However, in the case of curative
Defining acute care pose is to improve health. A proposed services, the relationship between time
Clear definitions of health systems and definition of acute care includes the and effectiveness varies, which makes it
services are required to create a com- health system components, or care de- important to get the patient to the right
mon language to encourage discussion livery platforms, used to treat sudden, place at the right time for the right in-
and help focus system development often unexpected, urgent or emergent tervention. Failure to consider the time
efforts. Health systems include all or- episodes of injury and illness that can component of curative services produces
ganizations, institutions and resources lead to death or disability without fragmentation through poor coordina-
“whose primary purpose is to promote, rapid intervention. The term acute care tion of care and the imprecise application
restore and/or maintain health”.1 Health encompasses a range of clinical health- of clinical interventions, such as delays in
services are “aimed at contributing to care functions, including emergency treating sepsis with antibiotics leading to
improved health or to the diagnosis, medicine, trauma care, pre-hospital death or disability. Fragmented care re-
treatment and rehabilitation of sick emergency care, acute care surgery, duces the number of disability-adjusted
people”, and they can be viewed from critical care, urgent care and short- life years (DALYs) that can be averted
several perspectives: (i) as actions to term inpatient stabilization (Fig. 1). with a given set of resources.
a
Department of Emergency Medicine, University of Maryland School of Medicine, 10 South Paca Street, Room 4S-127, Baltimore MD 21201, United States of America
(USA).
b
Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.
c
R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA.
d
Global Health Initiatives, University of Maryland, Baltimore, USA.
Correspondence to Jon Mark Hirshon (e-mail: jhirs001@umaryland.edu).
(Submitted: 9 September 2012 – Revised version received: 7 January 2013 – Accepted: 11 January 2013 – Published online: 31 January 2013 )
• Developing research methods of acute care systems towards the care Acknowledgements
to quantify the burden of acute of patients with communicable and The authors thank Linda J Kesselring for
care diseases and injuries, includ- non-communicable conditions and her valuable assistance.
ing health economics and cost- injuries. However, the creation of such
effectiveness components, to justify acute care systems should not be used Funding: JM Hirshon received funding
integrating acute care within health as a pretext for diverting resources to from the National Institutes of Health
systems. the construction of poorly-resourced Fogarty International Center (Grant
• Holding national and international and ill-managed health facilities. 5D43TW007296).
discussions to encourage better Aligning key players, both within
integration of acute care within local countries and across them, to support Competing interests: None declared.
and national health systems. the development of the best mix of
acute and preventive services needed
This paper is a call to action for to address the growing disease burden
leaders, policy-makers and academics is an urgent priority for health systems
to acknowledge the key contribution and society. ■
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Corrigendum
In Volume 91, Issue 3, March 2013, on page 169: the incidence of hospitalization for viral pneumonia among children aged 1-4 years in the pre-
vaccine era (July 1998 to June 2004) should be 770 per million person–years (originally published as 591).