Choosing Not to Turn Ambulances Away

OneVoice OneAction

Yudai Kaneda

Tokiwa Hospital, Tokiwakai FoundationJunior Resident

Young healthcare professionals are working energetically in communities across Japan. Where do the actions of these young people racing toward the future come from, and where are they headed? This series records the thoughts behind their work.

Fewer Difficult-to-Place Emergency Cases in Iwaki

“Iwaki Introduces New Holiday and Nighttime Rotation System, Cutting Difficult-to-Place Emergency Cases by 70% Year on Year in Two Months”—this was the headline of a newspaper article one day. A “difficult-to-place emergency case” refers to a situation in which emergency personnel must contact four or more medical institutions, or in which no receiving hospital can be found and the ambulance crew remains at the scene for 30 minutes or longer.

As a first-year physician at Tokiwa Hospital in Iwaki, which has fewer than 30 full-time doctors, I often find myself thinking how reassuring it would be if I could always turn to a specialist. In reality, however, patients brought in by ambulance do not arrive after choosing a hospital based on which specialist is available.

They simply want to receive medical care. In Iwaki, where that basic wish has not always been fulfilled, things are gradually beginning to change.

Emergency Patients Stranded Across Japan

Looking at national statistics, ambulances were dispatched 7,229,572 times in Japan in 2022. Nearly 19,800 ambulance crews are dispatched every day, amounting to a scale at which approximately one in every 20 people in Japan is transported by ambulance each year.

Meanwhile, cases in which no destination can be found and patients are effectively left stranded in the emergency care system continue unabated, exceeding 6,500 cases during peak weeks. Reasons cited by medical institutions for declining to accept patients include difficulty providing the necessary treatment, full bed occupancy, ongoing surgery or other emergency responses, cases outside the hospital’s specialty, and the absence of an appropriate physician.

Urban areas generally have more specialists and better-equipped facilities. Regional hospitals, by contrast, face structural constraints that force them to retain refusal as an option.

Tokiwa Hospital’s Challenge: Emergency Care That Does Not Say No

This April, Tokiwa Hospital, where I work, adopted the goal of “emergency care that does not turn patients away.” It is an against-the-grain initiative by a regional hospital seeking to confront precisely those constraints.

Under the leadership of Dr. Akihiko Ozaki, the ER2000 Project was launched, and this September the hospital achieved a record-high ambulance acceptance rate of 93.4% (198 of 212 cases). Considering that there was a month five years ago when the rate was only 36.0%, this represents a major leap forward.

One mechanism behind this change is “visualization.” The number of emergency cases accepted by each physician and their acceptance rates are posted on a whiteboard. Making these figures visible naturally prompts discussion within the medical staff about who is accepting patients and who is declining them.

At times, opinions clash. But by challenging the assumption that a patient “should be refused” with the question “Why?”, the prevailing attitude begins to shift toward “Let’s accept the patient first.” What changed was not the physicians’ skills, but their mindset.

The hospital has also introduced an incentive of ¥5,000 for each emergency case accepted. As a resident, I am not yet eligible for this program. Even so, I have repeatedly seen moments when the existence of the incentive leads senior physicians—the ones actually responsible for deciding whether to accept a patient—to think, “Well, let’s take the case.”

To be candid, there are times when I feel frustrated that even after I perform all of the treatment myself, the incentive goes to a senior physician simply because I am still a resident.

Even so, I see considerable value in the incentive because it acts as a nudge, spreading a hospital-wide atmosphere of “Let’s accept the patient.” An increase in acceptance means nothing less than moving patients’ desire to “see a doctor” one step closer to being fulfilled.

Even as a resident, being allowed to take part in a wide variety of cases regardless of specialty is helping me build the fundamental clinical strength I will need as a physician working on the front lines of regional healthcare.

Toward Becoming a “Community Doctor” with a Dual Role

And although I am not personally eligible for the financial incentives attached to clinical care, I am now exploring whether I can contribute by turning this initiative into academic research. Under Dr. Ozaki’s supervision, I have co-authored more than 50 papers indexed in PubMed since I was a medical student. That experience has enabled me to raise my hand when opportunities like this arise.

The challenges revealed through clinical practice can be made visible through research, and the insights gained through research can then be returned to the next round of clinical care. At Tokiwa Hospital, I have come to feel that within this cycle lies a path toward the sustainable development of community healthcare.

This article was originally published in Medical Times Web Edition on November 12, 2025.