The status of emergency medicine in the state of Kuwait

Abstract

Background and Objective of the review

There is limited literature on the emergency medicine (EM) specialty in Kuwait, and this paper evaluated the development status of the specialty under Arnold’s classification.

Discussion

In Kuwait, the EM specialty is recognized with an existing professional society and structured residency training program with post post-board-certification exam. The emergency departments are directed by board-certified emergency physicians with existing emergency medical services and transfer systems. However, there is still a huge demand for trained emergency physicians and a further need to advance the existing trauma system. The academic EM in the country needs further progress in research and developing a specialty journal, databases, and subspecialty training. The management systems within the emergency departments are well developed.

Conclusion

The EM status is its way to reaching maturity if we overcome a few deficits and challenges in the system. Lastly, two great achievements were made through the establishment of ‘the Kuwait Poison Control Center’ and the simulation training in EM.

Background

The state of Kuwait is a constitutional monarchy, and it claimed independence from the British protectorate on June 19, 1961 [1]. The country shares its borders with Iraq on the north-west border, Saudi Arabia on the south and south-west borders, and the Arabian Gulf coast on the eastern side (Fig. 1), and it has a land area of 17,82 km² divided into six governorates [2].The estimated population is about 4.92 million, with Kuwaitis accounting for nearly 32% [3]. Kuwait is a member of the Gulf Cooperation Council (GCC), which was formed in 1981 due to these countries' deep historical, social, religious, and cultural links [4].

Fig. 1

Map of the State of Kuwait (Al-Haroun, Y. (2015))

Kuwait's economy depends mainly on oil production, which was discovered in 1937. Oil revenues account for 90% of the total government revenues, and this opens the door to the prosperity of the Kuwaiti community [5]. In Kuwait, about 5.8% of the Gross Domestic Product (GDP) was spent on the public healthcare sector in 2021 [6]. Kuwait ranked 49 on the Human Development Index (HDI) with a value of 0.847 [7].

Healthcare system in Kuwait

Over the last two decades, the health system in Kuwait has evolved rapidly with significant advancements due to the increased government expenditure on the healthcare system, with 8.9% of total budget spending in 2019 leading to many healthcare public-sector projects completed or under construction [8]. This is reflected in the health index score, with a score of 77.3. Kuwait ranks 42nd globally and 3rd in the GCC countries after the United Arab Emirates and Qatar in 2023 [9]. In Kuwait, 80% of the healthcare is provided by the public sector, and the remaining 20% is provided by the private sector [10] (Fig. 2). The Ministry of Health (MOH) is the governing body for the healthcare system through a network of healthcare centers and hospitals in six different health districts. The health districts are Kuwait City, Hawali, Ahmadi, Al Jahra, Al Farwaniya and Al Sabah, and each district self-governs for financial, administrative, training, and management of healthcare delivery [11]. There are 14 hospitals and 93 healthcare centers and clinics under MOH [12], with ratios of physicians and nurses per 1000 populations of 2.9 and 7.1, respectively [8]. The MOH works closely with key stakeholders in national health workforce governance, which include but are not limited to the Kuwait Institute for Medical Specialization (KIMS), the Agency for Medical Responsibility, the Kuwait Medical Association (KMA), and Kuwait University [8].

Fig. 2

Providers of the Healthcare System in Kuwait

Emergency medicine specialty

Emergency Medicine (EM) is essential and valuable for different fields within the specialty and the healthcare system [13]. In line with the increased number of emergency physicians in EM, the specialty has undergone significant evolution, encompassing advancements in diagnostic techniques, treatment modalities, payment structures, and best practice guidelines. Additionally, EM has expanded its scope, giving rise to numerous subspecialties while continually exploring new frontiers in medical care [14]. Furthermore, some emergency departments (EDs) have evolved to include specialized units focused on specific patient groups and medical conditions, including orthopedics, oncology, and geriatric care so as to optimize patient treatment by concentrating expertise and resources, ultimately improving care quality and reducing overall healthcare costs [15].

The development of the EM system has been categorized into stages of underdeveloped, developing, and mature based on several features that look at the specialty, patient-care, and management systems, in addition to academic features [16]. EM specialty is considered well-established and mature in the United States (US), United Kingdom, Australia, Canada, Hong Kong, and Singapore, as the specialty witnessed an early development during the 70 s and 80 s [17]. Since then, EM has started its globalization journey to be recognized and developed in many countries across all continents [18]. However, the survey on the status of EM conducted by the American College of Emergency Physicians (ACEP) International Ambassador involving 63 countries around the world showed a high recognition of the specialty at 86%, but in low-income countries, the specialty still is in its developing stage with a limited number of emergency physicians, board-certified emergency physicians, and absence of EM peer-reviewed journals [19].

Emergency medicine in Kuwait

To our knowledge, this is the first paper to evaluate and discuss in detail the status of EM in Kuwait. To assess the status of EM specialty in the country appropriately, we applied the classification system proposed by Arnold to determine the level of EM development [16]. The classification permits proper guidance on EM development as it highlights areas in the system that are deficient and need development [17]. The domains of development of the EM system in Kuwait are summarized in Table 1. The data in this article was obtained from the Emergency Medical Council, Kuwait Board of Emergency Medicine (KBEM), Kuwait Society of Emergency Medicine (KSEM), and EM literature in the GCC countries. In addition, the authors include two Chairs of EM departments, Chair of Kuwait Emergency Medicine Council, Chair of KSEM, and board-certified emergency physicians with wide knowledge of EM and who are involved in KBEM.

Table 1 Stages of the development of EM system in Kuwait

Specialty systems

National organization

The KMA established in Kuwait on the 23rd of October 1963, is known to be the first professional medical association in the GCC countries. Now, about 19,635 registered physicians work in the governmental and private sectors [20]. KMA permits and supports the formation of societies for different medical specialties under its umbrella. In 2011, Kuwait followed other GCC countries and recognized EM specialty, and this was followed by the formation of the KSEM in 2014 [21] to serve and support emergency physicians. The society is active in organizing educational activities, which include workshops, courses, and conferences related to EM fields. So far, KSEM has hosted and organized two EM conferences dated back in March 2018 and February 2024.

Residency training and board certification

KIMS was established in 1984, and it became the pioneers for founding the postgraduate medical training in Kuwait and developing multiple medical specialties needed to serve the healthcare system [22]. Also, it undertook the role and engaged in forming general policies needed for training physicians and controlling the employment and assessment of the training programs. As part of international collaborations, KIMS had signed an agreement with the Royal College of Physicians and Surgeon of Canada to accredit its residency training programs [23], and meanwhile, KBEM program is under their assessment for accreditation in the near future.

Presently, KIMS runs 24 different residency training programs and 7 subspecialty programs. As part of KIMS, the KBEM began in 2011 with four residents [24]. The residency training programs is a five-year program that begins in October and concludes in September. The residency training program is concluded with a final end of training exam set by the Royal College of Physicians and Surgeon of Canada. Residents are awarded the Kuwait Board specialization certification at the end of the program [22]. Throughout the program, residents rotate through seven major general hospitals in Kuwait supervised by board-certified emergency physicians. Most rotations take place in emergency medicine departments, encompassing both adult and pediatric care. However, the program also includes essential rotations in areas pertinent to emergency medicine practice, such as adult and pediatric critical care, anesthesia, emergency medical services, and cardiac care. Additionally, residents gain exposure to other medical disciplines, including obstetrics and gynecology, orthopedic surgery, neurology, psychiatry, traumatology, and toxicology. Towards the end of the program, residents engage in rotations focused on administration and research, along with numerous elective months that cater to their specific interests. Electives may also be completed abroad, and many residents have successfully pursued this option in the past. Since 2011, 28 residents have completed the five-year program and received board certification. Currently, 49 residents are enrolled in KBEM from postgraduate year-1 (PGY-1) to PGY-5 as per Table 2. With an increasing number of board-accredited faculty, the number of available seats for 2025 has risen to ten, up from just four in 2011. Today, Kuwaiti Board-certified physicians are practicing emergency medicine in both public and private hospitals.

Table 2 Residents enrolled in KBEM

Academic EM

Specialty journal

There is no EM-specific peer-reviewed journal in Kuwait. However, KMA is responsible for issuing the Kuwait Medical Journal [25], which serves all the medical specialties within the association, including KSEM. Emergency physicians in Kuwait can also apply to other EM-specific peer-reviewed journals in GCC countries, such as the Saudi Journal of Emergency Medicine and the Journal of Emergency Medicine, Trauma and Acute Care in Qatar [21].

Research

In Kuwait, EM publications are still in the developing stage [21]. To advance the research activity, KBEM mandates that all residents participate in scholarly activities during their residency and attend the monthly journal club sessions. In addition, KSEM encourages research activities through training workshops and seminars. Another active source of research is the Kuwait Poison Control Center, which published several papers in the field of toxicology [26]. The EM scientific publications increased in the last decade with leading authors from US, Turkey, Canada, Australia, and China [27]. Unfortunately, the study did not represent Kuwait and other GCC countries. Emergency care research in the Middle East is still facing multiple obstacles, which were summarized into four groups: workforce and research training, research logistics and expertise, research ethics and presence of institutional review boards, and funding of research [28].

Database

All the EDs in Kuwait use an electronic health records (EHR) system. However, there is no unified national database because these systems are not linked. Emergency care database is an important tool because of its utilization of clinical information, data quality, data linkage, data usage, and covering the population [29].

Subspecialty training

At present, there is no subspecialty fellowship training in EM at KIMS. However, board-certified emergency physicians can apply for government-sponsored scholarships abroad [21]. Table 3 highlight the number of board-certified emergency physicians holding subspecialty certification and those who are still in-training. KBEM and KIMS are reviewing and assessing the start of subspecialty training programs in EM in the near future.

Table 3 Physicians with EM subspecialties in Kuwait

Patient care system

Emergency physicians

In Kuwait, the EDs are part of the structure of the public hospitals, and all are provided with state-of-the-art medical equipment and supplies to deal with various emergency patients. Under the MOH, the Emergency Departments Council implemented the Canadian Triage and Acuity Scale System (CTAS) in all the EDs to improve and standardize the triage system in the country [27].

General medical practitioners mostly staff the EDs. The number of board-certified emergency physicians from Kuwait and overseas residency programs is limited, and they mostly work in large EDs. Multiple factors can explain the shortage of emergency physicians in Kuwait [19]. First, the number of physicians exiting the KBEM and overseas residency programs is small compared to the current need. Secondly, there has been a rapid increase in the number of hospitals in Kuwait in the last few years, and most have EDs that need to be staffed with emergency physicians. Lastly, the EM specialty attracted insufficient Kuwaiti physicians for post-graduate training, as shown in a study conducted between 2003 and 2007 [30]. Though the study is old, the issue was never investigated nor revisited. This situation still exists in the US as the national EDs workforce included about 61% classified as emergency physicians, about 14% as nonemergency physicians (mainly from family practice and internal medicine), and about 24% as advanced practice providers [31].

ED director

All the EDs in Kuwait are chaired by board-certified emergency physicians, appointed by the MOH. Unique to Kuwait, the MOH established the Emergency Departments Council, which is represented by all the heads of EDs in the governmental hospitals and chaired by one of them. The council purpose is to; set the general clinical policies, procedures, and regulations to operates the EDs, provide expert opinion on competency for recruited emergency physicians applying to work in the EDs, develop the emergency disaster plan, and discuss any difficulties related to the services provided.

Prehospital care

The Emergency Medical Services (EMS) Directorate was established in 1988 under the MOH, and it provides EMS free of charge to all residents in Kuwait with 24/7 coverage through the emergency hotline number ‘112’ [21]. The hotline diverts its calls to the EMS Control Center, which is staffed with call takers, dispatchers, and supervisors, and through an electronic dispatch system, the calls get triaged, and instructions are given. The call taker will answer the call, take information from a caller, pass it to the dispatcher, and give instructions to the caller. The EMS Directorate controls 86 ambulance stations with a fleet of 200 ambulance vehicles and Helicopter EMS in its system [32], which is a two-tier system that adopts the Anglo-American model [21]. The ground and air ambulance crew workforce is represented by both genders, Kuwaiti and non-Kuwaiti, and a mixture of Emergency Medical Technicians (Basic, Intermediate, Advanced/Paramedic) and ambulance nurses who operate under online and off-line medical directions in the field [33].

Disaster preparedness

Disaster management in Kuwait is under the responsibility of the MOH and the Ministry of Interior, collaborating with representatives from other related ministries and agencies [21]. The EMS Directorate has established disaster and evacuation policy in collaboration with representatives from other related ministries and agencies to adopt their preparedness policies to be prepared for disaster situations. These policies were tested to examine and evaluate their strengths and deficiencies [34]. Also, Kuwait hosts the Arab Gulf States (AGS) Emergency Management Center to manage and organize activities between the AGS in emergencies and crises [34].

Transfer system

One of the critical components of the patient care system is the transfer structure, both intra- and inter-hospital patient transfers. This is important to enhance the patient’s medical management and to maintain the continuity care provided. All the EDs MOH transfer policy [33]. The policy provides information and sets standards for patient transfer within the hospital’s departments or other hospitals safely and efficiently in a multidisciplinary manner. Also, the policy clearly defines the rules and responsibilities of the EDs in such transfers. The EMS Directorate plays its part in the policy by transferring patients among hospitals through its fleet of ground and air ambulances.

Trauma system

Kuwait lacks a trauma registry, and the healthcare system is divided into 6 districts, each one has its own public hospitals that cover specific geographical areas. The EMS Directorate will transfer trauma patients according to the district to which the patients belong. Except for Al-Adan Hospital, which is trauma center, some of the remaining hospitals might have trauma teams working in coordination with their EDs. These hospitals can transfer trauma patients to specialized centers like Al-Razi Orthopedic and Rehabilitation Hospital and Ibn Sina Hospital for Neurology & Neurosurgery. The trauma system is evolving, with some existing components; however, it faces significant limitations, including the lack of legislation and a dedicated lead agency, a limited number of accredited trauma centers, and the absence of trauma registries and quality improvement programs, as noted in several Asian countries [35].

Management systems

Governmental EDs implement quality assurance programs through committees such as Safety & Risk Management, Mortality and Morbidity, Policies and Procedures, and Self-assessment & Peer Review. In addition, emergency physicians represent their EDs in other multidisciplinary committees in the hospitals, including Accreditation, Mortality and Morbidity, Infection Control, Blood Utilization, Antibiotic Stewardship, Electronic Medical Record, and Leadership.

Achievements

The Kuwait poison control center

The MOH established the Kuwait Poison Control Center in May 2023 at the Amiri Hospital as a national specialized center in toxicology. The center operates 24/7 through a hotline number (1,804,774) and provides consultations and advice on treatment plans for all poisoning and toxin cases, including radioactive materials and venomous animal bites and stings. The center director is a Kuwaiti board-certified emergency physician with a toxicology fellowship (Table 3). Also, the center collaborates with the World Health Organization and other regional toxicology centers [26].

Simulation in emergency medicine training

In recent years, simulation medicine has gained traction in the EDs across Kuwait, significantly enhancing the training and preparedness of healthcare professionals. There are three board-certified emergency physicians who are trained in simulation medicine (Table 3). Many departments have established dedicated simulation rooms, allowing staff to engage in realistic, hands-on training scenarios that improve their clinical skills and decision-making abilities. The concept started from Mubarak Al-Kabeer Hospital ED, where a simulation room was established and equipped with high-fidelity mannequins as well as specific trainers in 2018. Currently, similar rooms are available in most governmental hospitals EDs. This benefits the existing staff and serves as an invaluable resource for residents from various specialties rotating through the EDs, providing them with a safe environment to practice and refine their skills. As the integration of simulation medicine continues to expand, ongoing studies are exploring the development of a centralized simulation center that would support all EDs, further improving the quality of training and ultimately enhancing patient care across the nation.

Challenges

The major challenge is the shortage of Kuwaiti board-certified emergency physicians in the country, and this made the KBEM increase the number of training seats in the program to 10 residents per year [36]. Another challenge is the high portion of patients with CTAS triage levels of 4 and 5 presenting to the EDs, who should instead attend primary healthcare centers. The issue contributed to overcrowding and needs public education awareness and integration with the primary healthcare centers through the MOH. Farwaniya Hospital had established a fast-track unit within its ED to treat those patients. Finally, Kuwait holds a high incidence rate of fractures and fatality from motor vehicle accidents and occupational injuries, and this mandates the development of well-organized and integrated components of the trauma system in the country to provide effective and efficient healthcare for traumatic injuries.

Conclusions

Since its recognition as an independent specialty, the EM system in Kuwait is closely reaching maturity, with a few elements still in the developing stage, which need further advancements. These include the EDs databases, trauma system, and research status. The KBEM, KSEM, and the Emergency Departments Council led the specialty for significant advancements and achievements in a short period. Finally, the recognized challenges to the EM system should be studied profoundly and resolved with active solutions to improve the system.