Status of Emergency Medicine Around the World

EMERGENCY MEDICINE

IN GERMANY

PROF.DR.W.F.DICK

OVERVIEW

• Descriptive information/statistics– Country information– EM-Specialty status– EM system information

• Challenges/innovative strategies

• Summary

COUNTRY INFORMATION 1

• Federal Republic of Germany• Inhabitants:83 Mio (2001): 231 / Sqkm• Age: 0-14 y -12.6 Mio :15- 65y - 55.7 Mio:

> 65 y -14.0 Mio• Climate:Moderate • Finance: Compulsory Insurance• GNP/Capita: 24.650 €

COUNTRY INFORMATION 2„Burden of diseases“

• Life expectancy (years) : 81 F - 75 M• Major causes of mortality: 828.541 total

– Cardiovascular 30 %– Malignancy 10 %– Endocrine diseases: 3 %– Respiratory diseases 6 %– Trauma/Intoxications etc. 4 %– Various others 48 %

COUNTRY INFORMATION 3Health Care System

• Health Care System :Nat./Reg./Pub./Priv.

• Insurance compulsory: Public/Private

• Hospitals(except milit.): 2.240

of different categories

University Hospitals: 40

* Hospital beds (2001): 550.000 (80%)

COUNTRY INFORMATION 4MEDICAL EDUCATION

• Number of Medical Schools: 40

• Length of study: 6 years

• PG Training leading to

spezialisation 5-6 years

• Medical Specialty Board Final exam

certification

CONTACT INTERVALS

• The German EMSS has to guarantee a call-to-patient-contact-interval of:

- 10 minutes in 80 % - 15 minutes in 90 %

of all cases

EM-SPECIALTY STATUS

• EM is recognized as a supraspecialty to...not as a specialty of its own

• Recognizing bodies are regional medical councils

• Officially recognized for 2-10 years • Board certification process consists of a

training program and a final exam

EM-SUPRASPECIALTY STATUS 1

In addition to the curriculum of the base specialty, trainees have to undergo:

• 30 months hospital practice in emergency care, including 6 months ICU,ED and/or anesthesia under supervision and instruction of a state certified trainer........

EM-SUPRASPECIALTY STATUS 2

• 50 prehospital emergency operations(MLSU, helicopter etc.)under the guidance of an experienced EMPhy.

• A course program of 80 credit hours on general and special aspects of emergency medicine

• Final examination at regional medical councils

EM-SUPRASPECIALTY STATUS 3

• 1.Flight physiology 2 h

• 2.Medical equipment 4 h

• 3.Transport media 4 h

• 4.Flight safety 4 h

• 5.Documentation/TQM 2 h

• 6.Case scenarios 2 h

EM-SUPRASPECIALTY STATUS 4

• Red Cross and comparable organisations are concerned with prehospital EM(anesthesiologists, internists, surgeons

pediatricians )• In-hospital emergency care is provided by

different specialties

EM-SYSTEM INFORMATION 1

• Health Care is a responsibility of the Federal Government

• EM is a resonsibility of State Governments

• EM is considered as part of the transport system

• The EMS operates on local level

EM-SYSTEM INFORMATION 2

• Prehospital emergency care

Type of ambulances: Basic ( 2 EMTs) Advanced(1

Param. +1 EMT)MLSU( EMPhys..+ 2

Param.)

- EMT : 6 months- Paramedic : 2 years- EMPhys. : s.above

EM-SYSTEM INFORMATION 3DISPATCH MECHANISM

Bystander to dispatch center

public telephone or cellular phone

Dispatch center (paramedics + EMTs)

to ambulance or MLSU (paramedics)

via radio communication

EM-SYSTEM INFORMATION 4FUNDING

Funding is provided by health care insurance companies on a fee for service basis

• EMS-budget : < than 1 % of the total health care budget ( 1.25 Bio. € of 325 Bio.€ / year)

• Expenses /operation -Regular ambulance : 75 to 200 €-MLSU : 400 €-Helicopter : 40 €/Min

EM-SYSTEM INFORMATIONIN-HOSPITAL EMERGENCY CARE

• The scope of patient care provided depends on the case and the hospital category :– Basic Care– Intermediate Care– Maximum Care– „Supramaximum Care“

EM-SYSTEM INFORMATIONIN-HOSPITAL EMERGENCY CARE 2

• Intermediate and some maximum care hospitals provide emergency care in one central ED;

• other maximum and all supramaximum care hospitals provide EM in 2-3 separate „receiving areas“(surgical,internal,pediatric)

• Accordingly,the multispecialty approach is common, but based upon close cooperation with other hospital departments

CHALLENGES AND STRATEGIES

• TOP CHALLENGES1.EM is part of the public transport system

2.There is no general emergency phone number

3.Bystander preparedness is limited

4.Paramedic training program is under revision

5.Status and number of EMS-Medical Directors is insufficient

CHALLENGES AND STRATEGIES I

• TOP CHALLENGES1.Legislation requires EMS to be a component

of the public transport system;

i.e.the system is underfinanced due to the reimbursement system rather than by on scene patient care

CHALLENGES AND STRATEGIES 1

• TOP CHALLENGES2.There is no general public emergency phone

number

An emergency patient can either call 112 via cellular phone or 110 (Police) 112(fire fighters), 19222 (EMS dispatch center)or 19292(office based physicians)

CHALLENGES AND STRATEGIES I

• TOP CHALLENGES:3.Bystander preparedness is limited

According to study figures,only between 10 and30 % of bystanders are prepared or willing to carryout first aid measures.Ministeries and school administrations are rarelyhelpful in improving the situation

CHALLENGES AND STRATEGIES I

• TOP CHALLENGES:

4. Paramedic training programs are under revision:

The present 2- year training program is under

revision with respect to the status of

paramedics,their skills and capabilities

CHALLENGES AND STRATEGIES I

• TOP CHALLENGES5.Installation of EMS-Medical Directors

is insufficient

Among the various EMS-organisations,regionalRed Cross branches entirely oppose theinstallation of the position of a medicalEMS director responsible for all organisations

CHALLENGES AND STRATEGIES II

• Mechanisms by which strategies are developed and implemented are:- Discussion and development in GMC-councils,

critical care organisations etc.

- Presentation to the „Standing Conference of EM“

- Presentation to the political committees and

organisations

- Public hearings etc.

SUMMARY 1

• MAJOR POINTSCountry informationSpecialty and supraspecialty status situationSystem informationDispatch mechanism informationFunding mechanism informationIn-hospital emergency care situationChallenges and strategies

SUMMARY 2

• CONCLUSIONS+ All patients are financially covered(Insurances)

+ The system works fairly well ; however

- Structure and funding need to be improved

- Prehospital - and immediate in-hospital care have to be integrated

- One common emergency number ist needed

- Status of Medical Directors has to be improved

T H A N K Y O U

A n y Q U E S T I O N S ?