The increasing global population and its aging demographic are placing unprecedented demands on healthcare systems worldwide. This surge necessitates robust and responsive acute curative services capable of addressing life-threatening emergencies, sudden exacerbations of chronic illnesses, and numerous routine health issues requiring swift medical attention. Integrating emergency interventions and services with primary care and public health initiatives is crucial for building resilient and comprehensive healthcare systems. This article delves into the critical concept of acute care within this broader context, proposing working definitions, highlighting the consequences of fragmented service delivery, emphasizing the potential of acute care in integrated health systems, and outlining key steps for advancing Acute Care Health Programs globally.
Defining Acute Care Within Health Programs
Establishing clear definitions for health systems and their constituent services is paramount for fostering effective communication, promoting collaborative discussions, and guiding focused system development efforts. Health systems encompass all organizations, institutions, and resources primarily dedicated to promoting, restoring, and maintaining health.1 Health services, within these systems, are specifically “aimed at contributing to improved health or to the diagnosis, treatment and rehabilitation of sick people.”1,2 These services can be analyzed from various perspectives, including the organization of necessary inputs, the scope of promotion, prevention, cure, rehabilitation, and palliation, and their orientation towards individuals or populations.
Similarly, a precise definition of acute care is essential for effective healthcare planning and implementation. Standard medical definitions of acuity underscore the critical element of time sensitivity.3 Therefore, acute care health programs encompass all promotive, preventive, curative, rehabilitative, or palliative actions, whether directed at individuals or populations, with the primary goal of improving health. The effectiveness of these programs is intrinsically linked to timely and often rapid intervention.
While numerous individually-oriented services benefit from optimal delivery times, acute curative services stand out as the most time-critical, irrespective of the specific disease or condition. However, in many developing health systems, acute care has historically suffered from inadequate definition and insufficient support. A practical working definition of acute care should include the most time-sensitive, individually-oriented diagnostic and curative actions aimed at improving health outcomes. A more comprehensive definition of acute care health programs includes the essential health system components and care delivery platforms designed to manage sudden, often unexpected, urgent, or emergent episodes of injury and illness that pose a significant risk of death or disability without prompt intervention. The term acute care broadly encompasses a spectrum of critical clinical healthcare functions, including emergency medicine, trauma care, pre-hospital emergency care, acute care surgery, critical care, urgent care, and short-term inpatient stabilization, as illustrated in Figure 1.
Fig. 1. Domains within Acute Care Health Programs
a. Acute Surgical Care: Encompasses the treatment of individuals requiring immediate surgical intervention for conditions such as life-threatening injuries, acute appendicitis, or strangulated hernias.
b. Acute Medical and Surgical Emergency Care: Addresses the treatment of individuals facing acute life- or limb-threatening medical and potentially surgical emergencies, such as acute myocardial infarctions or cerebrovascular accidents, as well as the evaluation of patients with acute abdominal pain.
c. Urgent Ambulatory Care: Provides medical care outside of a traditional hospital emergency department setting, typically on an unscheduled, walk-in basis. Examples include the assessment of ankle injuries or fever in children. This is often a crucial entry point for acute care health programs.
d. Pre-Definitive Treatment Stabilization: Involves the immediate care provided to individuals with acute needs prior to the delivery of definitive treatment. This may include administering intravenous fluids to a critically injured patient before transfer to an operating room.
e. Pre-Hospital Emergency Care: Extends care into the community setting until the patient reaches a formal healthcare facility capable of providing definitive treatment. Examples include emergency medical services delivered by ambulance personnel or initial assessments by local healthcare providers. This is a foundational element of effective acute care health programs.
f. Critical Care (Intensive Care): Focuses on specialized care for patients with life-threatening conditions requiring comprehensive, continuous monitoring and advanced interventions, often within intensive care units. Examples include patients with severe respiratory distress requiring endotracheal intubation or those experiencing seizures due to conditions like cerebral malaria.
Fig. 1The Consequences of Fragmented Healthcare Systems on Acute Care Delivery
In 2007, the World Health Organization (WHO) emphasized the urgent need to strengthen global health systems.4 However, precise definitions and objectives, particularly concerning the delivery of health services, often remain ambiguous. Priority health problems are typically identified through consensus lists developed by countries with input from international organizations. Health services are then primarily directed towards preventing and controlling these prioritized health problems. A critical factor often overlooked in these processes is the influence of time on the effectiveness of interventions. Preventive strategies predominantly aim to reduce the incidence of new cases by mitigating disease risk factors. The earlier prevention efforts commence, the more rapidly incidence rates decline. Conversely, curative strategies focus on reducing disability or mortality among existing cases. The priority assigned to curative interventions is determined by their time-sensitivity, effectiveness, and cost-efficiency. However, the relationship between time and effectiveness in curative services varies significantly, underscoring the importance of ensuring patients receive the right intervention at the right place and at the right time. Neglecting the time-sensitive nature of curative services leads to fragmentation, characterized by poor care coordination and the imprecise application of clinical interventions. For instance, delays in administering antibiotics for sepsis can dramatically increase the risk of death or disability. Such fragmented care diminishes the potential to avert disability-adjusted life years (DALYs) with available resources, highlighting the critical need for integrated acute care health programs.
Acute Care Health Programs: A Cornerstone of Integrated Healthcare
As a vital clinical service, acute care directly addresses immediate threats to life or limb, regardless of the underlying cause. Therefore, robust acute care health programs are essential for fostering strong, horizontally integrated health systems, as opposed to fragmented, vertical programs that may improve outcomes for specific conditions but fail to strengthen the overall health system functionality. Notably, the essential material, consumable, and human resources required for effective acute care platforms often overlap significantly with those utilized in traditional “disease-centered” programs. Furthermore, common misconceptions surrounding acute care, such as equating it solely with ambulance transport or believing it to be fundamentally dependent on high technology, must be dispelled. In reality, excellent acute care is defined by its temporal element – the rapid response to immediate threats to life or limb – and involves strategic resource allocation to minimize preventable death and disability. The integration of well-structured acute care health programs with preventive and primary care services completes a comprehensive healthcare system paradigm that encompasses all essential aspects of healthcare delivery.
The prevailing conceptual framework for classifying health problems typically divides them into communicable diseases, noncommunicable diseases, and injuries. The ongoing global discourse surrounding noncommunicable diseases vividly illustrates how care can become fragmented when the time-critical nature of curative interventions is disregarded. Of the 57 million deaths globally in 2008, a staggering 36 million (63%) were attributed to noncommunicable diseases.5 A substantial and growing proportion of these deaths, along with deaths from injuries, occur in low- and middle-income countries undergoing rapid epidemiologic transitions.6 Strategies for addressing morbidity and mortality from noncommunicable diseases have predominantly focused on prevention and primary care initiatives. For example, the Prevention and control of noncommunicable diseases: guidelines for primary health care in low-resource settings provides comprehensive guidance for managing conditions like diabetes.7 However, time-sensitive measures are often relegated to only a few final points, despite the fact that conditions like diabetic ketoacidosis can be acutely life-threatening. The crucial contribution of acute care health programs in mitigating the escalating burden of disease and injuries has been significantly underestimated.
Acute care plays an indispensable role in preventing death and disability, a role that primary care, by its nature and resource limitations, is often unable to fulfill. Within comprehensive health systems, acute care also serves as a critical entry point for individuals experiencing emergent and urgent health crises. A well-defined concept of acute care facilitates the development of robust metrics for evaluating the effectiveness of acute care health programs, assessing the disease burden these programs address, and establishing clear goals for their advancement in low- and middle-income countries.8 The historically fragmented specialty areas falling under the umbrella of acute care have struggled to achieve substantial growth in their respective clinical domains at the international level, partly due to the absence of appropriate metrics and coordinated health service delivery. Conceptualizing acute care as an integrated care platform, embodied by comprehensive acute care health programs, enables these previously splintered areas to move forward with a unified agenda and a stronger collective voice.
Key Steps to Advance Acute Care Health Programs
Many simple, effective, and cost-efficient acute care interventions can be life-saving, often within the critical first 24 hours. These include interventions provided in basic surgery wards in district hospitals, offering essential treatment for trauma, high-risk pregnancies, and other common surgical emergencies.9,10 Discussions and initiatives surrounding acute care are gaining momentum, driven by visionary efforts such as the establishment of the African Federation for Emergency Medicine in 2009 and the Academic Emergency Medicine Consensus Conference dedicated to “Global health and emergency care: a research agenda” in 2013. However, several crucial steps are still necessary to further develop and strengthen acute care health programs worldwide. These include:
-
Developing Context-Specific Acute Care Service Delivery Models: Creating tailored acute care service delivery models specifically designed for low- and middle-income countries, operating in synergy with existing preventive and primary care services. These models should effectively address both life-threatening and limb-threatening conditions, as well as acute exacerbations of prevalent noncommunicable diseases.
-
Enhancing Interdisciplinary Coordination: Improving coordination and collaboration among various acute care service providers, such as emergency physicians, surgeons, obstetricians, and pre-hospital care teams, to ensure the efficient and effective delivery of critical acute care services within acute care health programs.
-
Establishing Robust Research Methodologies: Developing rigorous research methods to accurately quantify the burden of acute care diseases and injuries, including comprehensive health economics and cost-effectiveness analyses, to provide compelling justification for integrating and investing in acute care health programs within national health systems.
-
Fostering National and International Dialogue: Promoting national and international discussions and policy forums to encourage greater awareness and integration of acute care as a fundamental component of local and national health systems, emphasizing the role of well-structured acute care health programs.
This article serves as a call to action for leaders, policymakers, and academics to recognize the pivotal contribution of acute care health programs to the comprehensive care of patients with communicable and non-communicable conditions and injuries. However, the development of such programs must not serve as a justification for diverting resources towards poorly equipped or inadequately managed health facilities. Aligning key stakeholders, both within and across countries, to support the development of the optimal mix of acute and preventive services is an urgent priority for strengthening health systems and improving societal well-being. Prioritizing and investing in comprehensive acute care health programs is essential for building resilient and equitable healthcare systems capable of meeting the evolving health needs of populations globally.
Acknowledgements
The authors express their sincere gratitude to Linda J Kesselring for her invaluable assistance in the preparation of this manuscript.
Funding:
JM Hirshon received funding support from the National Institutes of Health Fogarty International Center (Grant 5D43TW007296).
Competing interests:
The authors declare no competing interests.
