The complexity of comparing different EMS systems—A survey of EMS systems in Europea

CONCEPTS

emergency medical services Europe

The Complexity of Comparing Different EMS Systems-A Survey of EMS Systems in Europe From the Department of Intensive Care and EmergencyMedicine, University of Antwerp, Antwerp, Belg4um. Receivedfor publication September 25, 1991. Revision receivedJuly 27, 1992. Accepted for publicationAugust i2, 1992. Presented at the Methodologyin CardiacArrest Researchsymposium in Chicago,April 1991.

Leo L Bossaert, MD, PhD

In Europe, emergency medical care has developed since the Middle Ages in each country, even within regions of a country, resulting in a patchwork of definitions, legislations, and systems. As a consequence,emergency medical care was implemented differently according to sociocultural, geographic, political, and religious differences between and within individual European countries. The objective of this survey was to describe the emergency medical services (EMS) systems in place throughout Europe, the type and qualification of the personnel, citizen-CPR knowledge, and experienceswith automated external defibrillator programs. In many Europeancountries, the active involvement in the field of physicians, as members of the first or the second tier, was observed as a major difference between European and US EMS systems. To evaluate and to compare performance of emergency medical care in different communities, detailed knowledge of all elements of the "cardiac arrestresuscitation complex" is required: the demographics of the community served by the EMS system, the structure and characteristics of each individual system, the epidemiology of cardiac arrest, the intervention process, and the outcome. To describe the EMS system, a uniform nomenclature is required. The Utstein "template" style could be proposed as the guideline to describe individual systems. The European Resuscitation Council could contribute in coordinating and standardizingthe various aspects of emergency medical care in Europe,with detailed registration, medical coordination, and medical regulation being the principal working rules. [Bossaert LL: The complexity of comparing different EMS systemsA survey of EMS systems in Europe. Ann EmergMedJanuary 1993;22:99-102.] INTRODUCTION In this review, the similarities and dissimilarities of various emergency medical services (EMS) systems in Europe are described. Evaluation and comparison of the performance

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EMS S Y S T E M S Bossaert

of emergency medical care in our communities require detailed knowledge of the different elements of the "cardiac arrest-resuscitation complex"---demographics of the community served by the EMS system; structure, characteristics, and function of each EMS system; epidemiology of cardiac arrest; intervention process; and outcome. Efforts have been made to address the differences of the EMS systems in place throughout Europe. In 1989, the World Health Organization (WHO) published a report on emergency medical care and public health education in the context of their project "Monitoring of the Strategy for Health for All by the Year 2000."~ In 1990, the Council of Europe compared the organization and functions of European EMS systems in regard to access, coordination, training, and medical control. 2 A questionnaire was mailed to the national representatives of the European Resuscitation Council to collect information about EMS system access, characteristics of participating rescuers, and transportation.3 HISTORICAL PERSPECTIVE

An organized EMS system was created in the 1 lth century by the order of Malta and the order of St John. Other EMS systems were in place in Rome (1 lth century), France (12th century), and Milan (14th to 16th centuries). The Red Cross was created by Henry Dunant in 1859, and the 0eneva Convention was established in 1864. Despite these early prototypes, emergency medical care has developed independently in each European country, and even within cities and regions of a country, resulting in a variety of definitions, legislations, and systems. In an early attempt to organize emergency care, the concept of the "chain of survival" was referred to in the late 1960s by Professor FW Ahnefeld in Germany; he described the sequential functions in the process of resuscitation, including first interventions and on-site first aid, access to the EMS system, medical care by emergency personnel, and medical care in the hospital. 4 In 1971, the Council of Europe recommended guidelines for organizing mutual help in case of disaster (Recommendation 645). In 1979, during a conference in Toulouse, France, the WHO Regional Office for Europe issued recommendations on planning and organization of EMS systems with an emphasis on the use of a unique telephone number for medical emergencies, regional coordination , appropriate training of all participants, qualification of participating hospitals, and appropriate medical involvement for coordination, field intervention, and training. In 1989,

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these recommendations were reinforced in the WHO project "Monitoring of the Strategy for Health for All by the Year 2000." In 1990, the multidisciplinary advisory European Resuscitation Council was created. It represents all European organizations and societies that are involved with resuscitation. Its primary objective is to improve the standards of resuscitation in Europe by coordinating the activities of European organizations with a legitimate interest in CPR. The secondary objectives of the European Resuscitation Council are to produce guidelines and recommendations appropriate to Europe for the practice of basic and advanced cardiopulmonary and cerebral resuscitation; to design teaching programs suitable for all trainees, ranging from the lay public to the physician; to conduct a critical review of CPR practices and to advise on updating guidelines; to promote and encourage appropriate research; to promote audit of resuscitation practice including standardization of records of resuscitation attempts; to organize relevant scientific meetings in Europe; and to promote political and public awareness of resuscitation requirements and practice. DEFINITIONS

In Europe, many definitions are used to describe the EMS system and its participants. These definitions must be known to interpret the structure and activities of individual EMS systems. To describe the EMS system in general, some definitions are descriptions of the crew (eg, Artzenotfalldienst, Artzenotdienst, service d'aide m4dicale urgente, servicio medico di urgenza, servicio medico urgencia, or urgent medical help system) or of the function (eg, Rettungsdienst, service d'urgences). The names given to the participating rescuers provide insight into the qualification of the rescuers. Examples of names for the first attending bystander include Ersthilfer, first aider, or samaritaner; first-line ambulancemen without additional training are called emergency medical technicians, auxilliaire aide medicale urgente, or ambulancier; and rescuers with additional training are called extended trained ambulance personnel, Rettungssanit~ter, paramedic, crash team, or Hying squad. Physicians participating in EMS are called, for example, ambulance and emergency doctor, medecin specialiste en aide m4dicale urgente m~decin urgentiste, or notartz. The names of emergency vehicles contain information about the crew or the function of that particular vehicle.

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EMS SYSTEMS Bossaert

Examples of vehicles used for transportation are Krankentransportwagen, Krankenwagen, ambulance de transport, and standard ambulance; vehicles for intervention are called ambulance de sauvetage, emergency ambulance, Rettungswagen, or autoambulanza di salvaggio; and vehicles with a medical intervention team on board are called ambulance m~dicalis~e, Notartzwagen, or clinimobil. In most European countries, emergency medical care is organized by law, whether a general nonspecific law related to the provision of mutual help or specific legislation related to the organization and functioning of the EMS system. TELEPHONE

NUMBERS

In most countries, a unique telephone number has been in use for many years (eg, 000~ 003,012, 03, 04, 15~ 100, 112, 113, 114, 115, 122, 144, 06-11, 90 000,996, or 999). In some countries (eg, Italy and Spain), the telephone number has not been implemented nationwide. However, a unique European telephone number is expected in the future. EMS

MODELS

Several EMS models are used depending on the country's demographic, cultural, and political situation. In some countries (eg, Belgium, Finland, Italy, Austria, and Switzerland), the EMS system can be considered an extension of the local hospital activity. In other countries, however (eg, France, Spain, Portugal, and the United

Table.

Different EM5 operating systems in some European countries

Country

Emergency Telephone No.

Austria Belgium

144 100

Finland France Germany Iceland Italy The Netherlands Norway

OOO 15 112 -118 06-11 003

Spain Sweden Switzerland United Kingdom

-90 000 114 999

First Tier

Second Tier

EMT* EMT (-D)t*

Physician Physician and nurse EMT(-D) Physician EMT Physician EMT Physician EMT (-D} Physician EMT (Physician) Nurse (EMT) -EMT-D Physician/ paramedic EMT (Physician) EMT-D Paramedic EMT EMT (-D) Paramedic

*EMT, ambulanceman with basic life support level training. *EMT-D, ambulanceman with basic life support-defibrillation level training. *Data in parentheses indicate exceptions.

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EMT-D

% Lay CPR

No Pilot

<5 10-20

Yes No Pilot Yes No No Yes

5-10 <5 10-20 5-10 <5 10-20 10-20

No Yes No Yes

<5 10-20 <5 5-10

Kingdom), the EMS system works without a structural link with the local hospital (Table). The different European EMS models can be summarized as one-tiered basic life support (BLS) without advanced life support (ALS) (the majority of Spain, Switzerland), one-tiered with physician or nurse first tier (The Netherlands, Eastern Europe), two-tiered with emergency medical technician-defibrillation (EMT-D) implemented in the first tier and paramedics in the second tier (United Kingdom, Sweden, initial experience in Germany), twotiered without implementation of EMT-D in the first tier and with physician or nurse in the second tier (most European countries), and two-tiered with EMT-D implemented in the first tier and physician or nurse in the second tier (Norway, pilot experiences in Germany and Belgium). The minimum training level of EMTs ranges between 20 and 520 hours. Specific training of paramedics is organized in the United Kingdom and Germany, whereas specific training of ambulance doctors is well organized in eastern European countries, Germany, France, and Spain. Early defibrillation by the first attending ambulanceman is implemented in the United Kingdom and Scandinavia. In Germany and Belgium, the usefulness of the EMT-D is under investigation, and a pilot program recently was initiated in Switzerland. CPR T R A I N I N G

OF THE

LAY

PUBLIC

CPR proficiency of the lay public is relatively good (10% to 20% of the adult lay population trained in BLS CPR) in the United Kingdom, Scandinavia, Belgium, and The Netherlands. In Germany, first aid training is widely implemented and is a prerequisite for a driver~ license; more than 20% of the lay public had first aid training, but CPR including chest compressions has been taught to the lay public only since the late 1980s. 5 Training levels are lower in Mediterranean and Eastern European countries. RECORDKEEPING

AND

PERFORMANCE

DATA

Systematic registration of EMS interventions is more an exception than a rule. Therefore, limited data are available from the United Kingdom, Scandinavia, Belgium, and The Netherlands on performance in terms of intervention times, case mix, and survival. SUMMARY

Study of the differences and similarities of European EMS systems results in many conclusions and recommendations. Emergency medical care is widely accepted in all European

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EMS SYSTEMS Bossaert

countries but implemented differently in individual countries. The wide range of EMS models is a reflection of the marked sociocultural, geographic, political, and religious differences between and within European countries. In most European countries, the medical involvement and medical presence in the field are most important, whether it is the first tier as in Eastern European countries or the second tier as in several Western European countries. However, in a few countries, specific qualifications and training are required for participating physicians, and the specialty of emergency medicine does not exist. To interpret the performance of the EMS systems in European countries, a detailed description of the system is required. Performance data, which are limited in Scandinavia, the United Kingdom, The Netherlands, and Belgium, are hard to compare. The Utstein template style for uniform reporting of data on cardiac arrest and an equivalent method of reporting data on other medical emergencies could be proposed as a guideline to describe individual EMS systems. There is an urgent need for coordination and uniformity of the various aspects of emergency medical care in Europe, including registration, medical coordination, and medical regulations. The European Resuscitation Council is involved in developing and implementing a standardized European format for reporting CPR interventions.

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REFERENCES 1. WHO RegionalOffice for Europe:Monitoring of the Strategy for Health for All by the Year 2000. Copenhagen,WHO RegionalOffice for Europe,1989. 2. Conseilde l'Europe: Etude Comparativesur I'Organisation et le Fonctionnementdes Services d'Aide M#dicale Urgente[Comparative Study of the Organizationand Functioning of Emergency MedicalAssistance Services]. Strasbeurg,Oonseilde I'Europe, 1990. 3. Bissell 8, CenaverJ: International emergencyhealth care systemssurvey. PrehospOisas Med 1991;6:149-158. 4. CumminsR, ChamberlainD, at al: Special report: Recommendedguidelinesfor uniform reporting of data from out-of-hospital cardiacarrest. Circulation 19g;;84:960-975. 5. KuschinskyB, SchmiedelR, Unterkofler M: Erste Hitfe in tier BundesrepublikDeutschland. Untersuchungenzum Rettungswesen.Bericht 18. DeutschesRotesKreuz,Bonn, 1986. Personal communications were kindly provided by members of the European Resuscitation Council and other individuals: F Ammirati, R Beckers, M Boidin, M Chanteloup, K Cvachovec, W Dick, Y Donchin, M Halinen, S Hapnes, S Halmberg, R Juchems, P Knuth, A Lemkens, H LNIgen, A Marsden, JC Mercier, 0 Moeschrer, P Mottironi, 00lafson, N Perales, P Petit, M Pistolese, M Rolloni, W RSse, 6 Thorgeirsson, M Van Bouwelen, L Van Rillaer, and M van Plant&

Address for reprints: Lee L Bossaert, UD, PhD

Universityof Antwerp-UIA Depatrnent of Medicine Universiteitsplein1 B2610Antwerp, Belgium

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