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Emergency medicine in Poland
Resuscitation (2007) 75, 213—218
INTERNATIONAL EMS SYSTEMS
Emergency medicine in Poland Waldemar Hladki b,c,∗, Janusz Andres a,1, Marek Trybus d,2, Rafal Drwila a,e,3 a
Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University School of Medicine Krakow, Kopernika Str. 17, 31-501 Krakow, Poland b University Hospital Emergency Department, Jagiellonian University School of Medicine in Krakow, Kopernika Str. 17, 31-501 Krakow, Poland c Regional Department of Polish Society of Emergency Medicine in Malopolska Province, Poland d Emergency Medicine and Multiple Trauma Clinic, Jagiellonian University School of Medicine, Krakow, Kopernika Str. 21, 31-501 Krak´ ow, Poland e Anesthesiology and Intensive Care Medicine, Jagiellonian University School of Medicine, Department of Intensive Care Medicine, John Paul II Hospital, Pradnicka Str. 80, 31-202 Krakow, Poland Received 6 June 2007; accepted 11 June 2007 KEYWORDS EMS; Emergency medicine; Emergency Department
Summary The article describes the feature of Poland’s emergency medicine services system. Pre-hospital emergency medical service (EMS) access, regional differences and the main features of the system are described. EMS personal education and skill level are discussed. The authors offer a critical analysis of the current situation and proposal for the future development of emergency medicine in Poland based on changes in law, organization and education. © 2007 Elsevier Ireland Ltd. All rights reserved.
Background
∗
Corresponding author at: University School of Medicine Krakow, Kopernika Str. 21, 31-501 Krakow, Poland. Tel.: +48 12 635 16 87; fax: +48 12 635 16 87. E-mail addresses: [email protected] (W. Hladki), [email protected] (J. Andres), m [email protected] (M. Trybus), [email protected] (R. Drwila). URL: http://www.prc.krakow.pl (J. Andres). 1 Tel.: +48 12 424 77 97; fax: +48 12 424 77 97. 2 Tel.: +48 12 424 82 01. 3 Tel.: +48 12 614 33 62; fax: +48 12 614 33 62.
Poland is a large country situated in central Europe. It stretches from the Tatra Mountains in the south to the Baltic Sea in the north. The land area is 312,000 km2 and the area of its territorial sea is 781 km2 . The territory has the shape of an irregular square with a south-north distance of 649 km and a west-east distance of 689 km. The country comprises various geographical regions with the mountains in the south, seaside lowlands in the north, a ‘‘land of thousands of lakes’’ in the northeast and plains in the central part. The country
0300-9572/$ — see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2007.06.005
214 has a population of over 38 million inhabitants and the mean population density is 122 persons/km2 . Females account for about 54% of the whole population. Average life expectancy of females is 79 years and of males is 71 years. An increase in the percentage of elderly people has been observed in the last two decades. 62% of the population live in urban areas and the ratio of urban to rural population has remained stable for several years; females slightly outnumber males in the cities.1 Generally accessible health care in Poland is assured by the state and is covered mainly by basic health insurance funded from taxation. The majority of hospitals are in state ownership, however in recent years a considerable number of health care centres and a small number of hospitals have been privatized. A total of 76,000 doctors are employed in health care services in Poland. The predominant health problems of Polish society are ‘civilisation’ diseases, such as circulatory diseases, malignancy, injuries and poisonings, which constitute 80% of all disease treated. Each year there are over 5,500 deaths and 65,000 injuries due to traffic accidents. For every 100 accidents, 11 people are killed, compared to 3 per 100 accidents in other European Union countries. The economic and social costs of disease are high. The direct costs alone are estimated at over D 4 billion annually, which constitutes 21% of the gross national product. Emergency medical care is 99% state-financed. It provides a nationwide service and is part of an integrated system which is closely related to and co-operates with the State Emergency Medical Care and Fire-fighting Services.1—4 Because of geographical and demographic diversity, as well as a diversity of threats in various provinces, there are regional differences in emergency medical services. Substantial differences are observed between the southern, western and central regions and the eastern and northern regions of the country. The main problems of the Mazovian Province, inhabited by over 5 million including the Warsaw conurbation (3 million) and the capital of the country (1.7 million), are traffic accidents and diseases of civilisation. There is an average 45.6 hospital beds per 10,000 inhabitants and 1842 patients/10,000 inhabitants are treated annually. There are 18 hospital emergency departments in this province. The highly industrialised and polluted Silesian Province with almost 4.7 million inhabitants and a mean population density of 380 persons/km2 has a high rate of traffic and industrial accidents. The average number of hospital beds is 57.1 per 10,000 inhabitants, the number of in-patients is 1805/10,000 inhabitants and the num-
W. Hladki et al. ber of medical consultations provided annually is 6.8 per inhabitant. There are 12 emergency departments in this province. The Malopolska Province (3.1 million) is a mainly mountainous area with a well developed industry and includes the Krakow conurbation (1.2 million inhabitants) and has average population density of 250 persons/1 km2 .1,5—8 It receives the greatest number of tourists annually, the majority of whom are from abroad. There are 22 emergency departments. These three provinces comprise the greatest number of emergency departments of all provinces in the country. There are some provinces with a lower number of inhabitants and lower population density, e.g. the Podlaskie Province (1.2 million inhabitants) and population density of 59.4 persons/km2 where there are fewer challenges for the emergency medical service and therefore the number of emergency departments is proportionally smaller, 9.1 A first responder service based on ambulance teams, Helicopter Emergency Medical Services and emergency departments has been functioning since the end of the World War II in co-operation with the State Fire-fighting Service. In 1995 the State Emergency Care and Fire-fighting System (SECAFS) was created, the aim of which was to standardise the rescue functions formerly carried out by the State Fire-fighting Service. The SECAFS coordinates the fire-fighting and rescue functions at sites of catastrophes and natural disasters in co-operation with technical, ecological and medical emergency services in all Polish counties and provinces. The state emergency care system constitutes an integral part of the countries security system. The SECAFS includes 508 emergency care and fire-fighting centres and 3433 voluntary fire brigades. Currently all fire-fighters are licensed paramedics. The State Emergency Care and Fire-fighting Service comprises 11 hospitals, 10 of which are owned by the Ministry of Interior Affairs and Administration (in Warszawa, Krak´ ow, Pozna´ n, Ł´ od´z, Olsztyn, Katowice, Białystok, Lublin, Szczecin and Wrocław) and the Burns Treatment Centre in Siemianowice ´ Sl˛ askie. The SECAFS also includes the Marine Search and Rescue Service, Mining Rescue Service, Police, Emergency Medical Service, Border Guard, State Inspection of Environment Protection, State Atomic Physics Agency, Institute of Meteorology and Water Exploitation, as well as extra-governmental organisations, such as Volunteer Mountain Search and Rescue Service, Volunteer Water Rescue Service, Volunteer Tatra Rescue Service, Polish Aero-club, Association of Polish Scouts, Polish Medical Mission and the Polish Red Cross.3,4
Emergency medicine in Poland In 1999 the formation of a uniform, integrated and modern Polish emergency medial care system was begun to improve the rescue service under SECAFS guidelines. The main aims of this new service were improvement of emergency patient transport, decrease in death rates during the prehospital phase of care and reducing the time between scene and arrival at an appropriate health care facility. The main areas that required immediate and effective improvement were: pre-hospital care, integration of emergency medical services with other emergency subjects, hospital emergency care and education in the field of emergency medicine.2,9,10 The first stage of the Ministry of Health programme was called ‘‘Integrated Emergency Care’’ and was completed in the years 1999—2002. It was state-financed and based on the State Emergency Medical Care Act passed on July 25th 2001, the socalled ‘‘Mother Act’’ and the government executive orders passed in the years 2002—2005. The programme targets that were achieved by December 30th 2004 included: 1. Provision of an adequate number of ambulances to attend the injured/sick within 9 min within the city and 15 min outside the city in at least 50% of cases. These targets were set by the Medical Emergency Act and required a total of 1140 ambulances for the whole country.11,12 2. Creation of 130 dispatch centres to ensure effective ambulance dispatch. 3. Building 278 emergency departments (1 hospital emergency department per 150,000 inhabitants and 16 paediatric emergency departments). After the requirement for personnel educated in emergency medicine was recognised 2000 specialty training posts in emergency medicine for doctors were created, and emergency medicine soon became a the basic medical specialty in Poland. Originally, this kind of specialty training was done, within a ‘‘shortened specialty pathway’’, by specialists in other medical fields, such as, anaesthesiology and intensive therapy, general surgery, internal medicine and paediatrics. The first specialty training in emergency medicine was completed in 2003. The duration of specialty training in emergency medicine is now 5 years. Since 2002, undergraduate courses have been run for paramedics in medical universities and colleges. Also undergraduate studies in the field of emergency medicine are conducted in eight state medical universities. Moreover, students of the medical faculty have to undergo a compulsory emergency medicine training finishing with an examination held in the last year of the 6-
215 year medical studies. Nurses can also specialise in emergency medicine during a 2-year specialty training followed by a special state examination. Courses are also used to educate dispatchers. The Polish Resuscitation Council (founded in 2001, http://www.prc.krakow.pl) and the Polish Emergency Medicine Association play an important role in specialty courses and training in emergency medicine for doctors. Certified courses in BLS/AED, ILS, ALS, EPLS, BTLS, PALS and ATLS are available. These organisations also contribute to trainings in first aid for various professional groups: e.g. teachers, policemen, firemen, flight attendants, security guards, etc. International Championships in Emergency Medical Care and Road Rescue are organised annually in Poland providing opportunities to improve rescue skills.
Pre-hospital care Pre-hospital medical care in Poland consists of various components of an integrated emergency medical care system including dispatch centres, rescue teams, Helicopter Emergency Medical Service and fire brigades. Dispatch centres belong to the State Emergency Care and Fire-fighting System. The main duty of the dispatch centres is receiving emergency calls (phone numbers are 999, 998, 112), assessment of the received information and the dispatch of an emergency service team to the scene. Currently telephone calls to 112 are re-routed by the police to the despatch centre. Dispatch centres frequently include fire brigade controllers and emergency medical service controllers. In Poland there are a total of 155 dispatch centres which exceeds the number originally projected.2,13,14 The ambulance service is provided by the emergency medical service and provides trained rescue teams. The Polish emergency medical service includes several types of ambulance vehicles distinguished by letters painted on the vehicle body.15,16 Resuscitation ambulances (R) are used in life threatening conditions. The ambulance rescue team consists of a doctor (a specialist in emergency medicine, an anaesthesiologist or an internist on a specialty training programme in emergency medicine), a paramedic, emergency nurse or two paramedics and an ambulance driver. Accident ambulances (W), also called primary ambulances are dispatched where a resuscitation ambulance is not necessary or where there is no ‘‘R’’ team available. The equipment on the ‘‘R’’ and ‘‘W’’ ambulances are almost identical. A ‘‘W’’ ambulance team usually consists of a doctor and an
216 emergency nurse or paramedic who are licensed to perform rescue interventions. The team of a ‘‘W’’ ambulance may not include a doctor, and one of the rescue team members possessing a driving licence for priority vehicles can drive the ambulance. If none of the team members has got such a licence, a vehicle driver has to be included to the team. Transport ambulances (P), used for the transport of patients not requiring pre-hospital intensive care or blood transfusion, comprise a driver and a paramedic. From 2007 transport ambulance teams can work with a paramedic and without a doctor. These ambulances are not included in the integrated emergency medical service, but in hospital emergency departments.17 Neonatal ambulances (N), are used for transport of neonates and infants. Generally, ambulances are stationed in ambulance bases collocated with hospital emergency departments, in ambulance stations outside hospitals and in fire-fighting units. In Poland about 1400 ambulances are contracted to provide the emergency medical service, which meets the country’s requirements. The mean response times in rural and urban areas are close to the norms accepted in the European Union. Krak´ ow has one of the oldest civil municipal ambulance stations in the world (the third after Vienna and Budapest) founded in 1891. The Helicopter Emergency Medical Service is a separate public health care unit subordinate to the Minister of Health, providing an emergency medical service and transport.13,18,19 Presently, Helicopter Emergency Medical Services include 16 permanent bases, 2 seasonal bases in the Pomeranian and Mazurian regions working only in summer (18 Mi-2plus helicopters). Apart from the Helicopter Emergency Medical Service, in the Tatra Mountains, a W3A ‘‘Sok´ oł’’ helicopter belonging to the Voluntary Tatra Mountains Search and Rescue service is used. The area of activities of the Helicopter Emergency Medical Service includes the majority of the country territory. The equipment and personnel of the helicopters are similar to those of the resuscitation ambulances. They are used to aid overloaded ambulance medical teams or for cases requiring immediate transport of the injured to a special hospital facility. Rescue activities are performed by Mi-2plus helicopters and transport is ensured by Augusta A109E Power helicopters and Piaggio P-118 Avanti and PZL M-Mewa aeroplanes. By 2010, the purchase of 23 new helicopters and one flight simulator is planned. In some big cities in Poland there are also motor cycle emergency medical services with a paramedic. Occasionally, rescue boats including motorboats are used for emergency transport by water. The work of rescue teams is financed from the state budget.
W. Hladki et al.
Emergency department Emergency departments are another element of the integrated emergency medical care system in Poland. At present there are 150 medical departments. They are situated in hospitals which where it is mandatory to have an intensive therapy unit, general surgery and trauma surgery departments, an internal medicine department, radiology department and diagnostic laboratories. They may also contain departments of cardiology, paediatrics, neurology, gynaecology and obstetrics, dialysis unit and a landing field for helicopters but this is not mandatory. In Poland, the tasks of the emergency departments are: stabilisation of the patient’s condition, initial diagnosis and treatment of a wide range of acute cases, poisoning and major injuries. Generally, emergency departments deal with patients who are brought by emergency teams and the also those who report to the hospital by themselves. The care for mass casualties is provided according to county or provincial guidelines for emergency medical services. Other tasks of the emergency departments include collection and storage of documentation and supervision and assessment of the activities of the units of the integrated emergency medical services in the catchment area of the emergency departments.7,8,13,20—23 The emergency departments in certain major hospitals are accredited to conduct training and courses in emergency medicine. Currently, there are 32 such emergency departments but the ultimate number proposed by the Ministry of Health is 118. Each emergency department has to contain all necessary areas including an assessment area, observation, shortterm intensive therapy, resuscitation, surgery, consultation, diagnostics and laboratories. In the last 7 years a large sum of money has been spent to equip the emergency departments with emergency equipment in accordance with the State Emergency Medical Care Act and European Union standard guidelines. The staff working in the emergency departments consist of emergency physicians, doctors on specialty training in emergency medicine, anaesthesiology, internal medicine, general and trauma surgery and specialists in other medical disciplines. Approximately 100 patients are admitted to the emergency departments daily. The survey conducted on March 1st 2007 in Poland showed a total of 458 emergency physicians and 465 doctors undertaking specialty training in emergency medicine. The emergency departments also employ paramedics and emergency nurses. In 2006 the first specialisation exam in emergency nursing was organised for 115 nurses. There is still a short-
Emergency medicine in Poland age of emergency departments in Polish hospitals. To ensure full emergency medical care, about 100 more emergency departments will be required. For example, Mazovian province has a deficiency of 10 emergency departments, Silesian province 14 and Podlaskie province 4. In these provinces, admission rooms serve as a substitute for the missing emergency departments. Only Malopolska Province has the required number of emergency departments. Hospital emergency departments are financed by the State Health Fund. During a short, 10-year period of development of a modern emergency medical care system in Poland many problems have been encountered including getting emergency medicine recognised as a specialty, financial problems and meeting high local demands and expectations. Considerable progress has been made in building an integrated, modern emergency care system. In some provinces emergency medical services fully meet the inhabitants’ needs in emergency medical care in terms of numbers of ambulances and dispatch centres. In the next 2—3 years the remaining emergency departments are to be completed; work has already commenced. Moreover, a network of highly specialised life-rescue centres is being formed (centres for trauma, stroke, burns, poisoning and interventional cardiology) for the purpose of improving the effectiveness of emergency services in Poland. The Act of the State Emergency Care, which was passed on 1st January 2007 regulates the emergency service system and assures the financial support of the emergency departments. The Act makes the provincial governors responsible for the activity of local emergency medical services. It allows the use of staffed ambulances without doctors, only with paramedics who are licensed to perform a wide range of rescue procedures. The Act was formed on the basis of ‘‘Mother Act’’ about the State Emergency Care System from 2001.17,18 Currently, the most urgent problems to solve are: (1) the separation of the tasks of primary medical care and family medicine from the tasks of emergency medical care; (2) the increase in the number of emergency departments to 250; (3) the assurance of appropriate funding of emergency departments both for the operational readiness financed from the state budget and for the performance of medical procedures financed from the National Health Fund; (4) the increase in the number of accredited training departments to 118 to ensure an adequate number of training opportunities in emergency medicine; (5) the increase in the number of doctors (by 600) admitted for specialty training in emergency medicine; (6) education of a total number of 4500—5000 specialists in
217 emergency medicine working for emergency medical service; (7) providing continuous education and supplementary courses in emergency medicine for nurses and paramedics; (8) improvement of the professional competence of nurses, paramedics and dispatchers by creation of in-service obligatory courses for them (one every 5 years); (9) standardisation of the curriculum for undergraduate education. It should be pointed out that in most developed countries the formation of a modern emergency system took considerable time (approximately 20 years). During this period it was impossible to avoid making mistakes, and because of its specificity, the emergency medical service is still not perfect. The greatest potential for emergency medical care in Poland lies in its people, their knowledge, enthusiasm, willingness for further education and unshakable belief in final success. The basis for the activities of the state emergency system is the Polish Association of Emergency Medicine, the Polish Council of Resuscitation and the Polish Government with its agencies. The greatest problem of emergency medical service system in Poland is the limited financial resources available.
Conflict of interest None.
References 1. Statistical yearbook of Poland 2005. Warszawa: Main Statistical Office, Zakład Wydawnictw Statystycznych; 2005. 2. Programme of Integrated Medical Emergency in 2002 (continuation of the Programme 1999—2001). Ministry of Health, Warsaw, 2002. 3. http://pl.wikipedia.org/wiki/Krajowy system ratowniczoga´sniczy 4. Marczy´ nski D, Grosset R. Organization of emergency medical care in the national emergency-firefighting system. Health Manage 2000;2:24—30. 5. Guła P, Popławska M, G´ orski K, Hładki W, Brongel L. Emergency medical service in Krakow—–looking for the perspective of EMS in Poland. 6 Congress of European Society of Trauma Surgery. Eur J Trauma 2004;30(Suppl. 1):59. 6. Guła P, Kosi´ nski S, Hładki W, Brongel L. Sudden cardiac arrest in remote mountain areas. Eight Congress of the European Resuscitation Council. Resuscitation 2006;69:116—7. 7. Brongel L, Popławska M, Hładki W, Guła P. Organization of the network of emergency departments in Krak´ ow conurbation. Intensive Emerg Med 2004;7(Suppl.):122—4. 8. Hładki W, Popławska M, Brongel L, Wojtas A, Guła P. Clinical material of the emergency department SU and KPR in the aspect of efficiency of primary health care. Intensive Emerg Med 2004;7(Suppl.):141—2. 9. Skowro´ nski R. First aid in the National Emergency Care Act. Health Manage 2001;3:92—4.
218 10. http://www.lifemed.pl 11. http://www.mz.gov.pl/wwwmz/slajd 12. Hładki W, Brongel L, Popławska M. Current situation and perspectives of progress in emergency medicine. In: International Conference ‘‘Urban Crisis Management in Europe at the Beginning of the Third Millennium’’. 2003. 13. http://pl.wikipedia.org/wiki/Ratownictwo medyczne 14. http://wikipedia.org/wiki/Centrum powiadaniaratunkowego 15. http://pl.wikipedia.org/wiki/Ambulans 16. http://pl.wikipedia.org/wiki/Pogotowie Ratunkowe 17. The National Emergency Medical Care Act on September 8th 2006. The Ministry of Health (Dz.U. nr 191, poz. 1410). 18. http://pl.wikipedia.org/wiki/Lotnicze Pogotowie Ratunkowe
W. Hladki et al. 19. Guła P, Brongel L, Hładki W. Helicopter Emergency Medical Service in Krakow region. 6 Congress of European Society of Trauma Surgery. Eur J Trauma 2004;30(Suppl. 1):59. 20. Guła P, Hładki W, Brongel L. Mass casualty events. Med Rev 2006;63(Suppl. 5):5—8. 21. Hładki W, Trybus M, Lorkowski J, Brongel L. Achievements of the bones and joints decade in emergency medical care. Med Rev 2006;63(Suppl. 5):14—6. 22. Jakubaszko J. Organizational and functional standards of the emergency department in the Act of ‘‘health and life rescue in a sudden threat’’. Health Manage 2000;2:18—23. 23. The Ministry of Health order on May 10th 2002 about emergency departments (Dz.U. nr 74, poz.678).
INTERNATIONAL EMS SYSTEMS
Emergency medicine in Poland Waldemar Hladki b,c,∗, Janusz Andres a,1, Marek Trybus d,2, Rafal Drwila a,e,3 a
Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University School of Medicine Krakow, Kopernika Str. 17, 31-501 Krakow, Poland b University Hospital Emergency Department, Jagiellonian University School of Medicine in Krakow, Kopernika Str. 17, 31-501 Krakow, Poland c Regional Department of Polish Society of Emergency Medicine in Malopolska Province, Poland d Emergency Medicine and Multiple Trauma Clinic, Jagiellonian University School of Medicine, Krakow, Kopernika Str. 21, 31-501 Krak´ ow, Poland e Anesthesiology and Intensive Care Medicine, Jagiellonian University School of Medicine, Department of Intensive Care Medicine, John Paul II Hospital, Pradnicka Str. 80, 31-202 Krakow, Poland Received 6 June 2007; accepted 11 June 2007 KEYWORDS EMS; Emergency medicine; Emergency Department
Summary The article describes the feature of Poland’s emergency medicine services system. Pre-hospital emergency medical service (EMS) access, regional differences and the main features of the system are described. EMS personal education and skill level are discussed. The authors offer a critical analysis of the current situation and proposal for the future development of emergency medicine in Poland based on changes in law, organization and education. © 2007 Elsevier Ireland Ltd. All rights reserved.
Background
∗
Corresponding author at: University School of Medicine Krakow, Kopernika Str. 21, 31-501 Krakow, Poland. Tel.: +48 12 635 16 87; fax: +48 12 635 16 87. E-mail addresses: [email protected] (W. Hladki), [email protected] (J. Andres), m [email protected] (M. Trybus), [email protected] (R. Drwila). URL: http://www.prc.krakow.pl (J. Andres). 1 Tel.: +48 12 424 77 97; fax: +48 12 424 77 97. 2 Tel.: +48 12 424 82 01. 3 Tel.: +48 12 614 33 62; fax: +48 12 614 33 62.
Poland is a large country situated in central Europe. It stretches from the Tatra Mountains in the south to the Baltic Sea in the north. The land area is 312,000 km2 and the area of its territorial sea is 781 km2 . The territory has the shape of an irregular square with a south-north distance of 649 km and a west-east distance of 689 km. The country comprises various geographical regions with the mountains in the south, seaside lowlands in the north, a ‘‘land of thousands of lakes’’ in the northeast and plains in the central part. The country
0300-9572/$ — see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2007.06.005
214 has a population of over 38 million inhabitants and the mean population density is 122 persons/km2 . Females account for about 54% of the whole population. Average life expectancy of females is 79 years and of males is 71 years. An increase in the percentage of elderly people has been observed in the last two decades. 62% of the population live in urban areas and the ratio of urban to rural population has remained stable for several years; females slightly outnumber males in the cities.1 Generally accessible health care in Poland is assured by the state and is covered mainly by basic health insurance funded from taxation. The majority of hospitals are in state ownership, however in recent years a considerable number of health care centres and a small number of hospitals have been privatized. A total of 76,000 doctors are employed in health care services in Poland. The predominant health problems of Polish society are ‘civilisation’ diseases, such as circulatory diseases, malignancy, injuries and poisonings, which constitute 80% of all disease treated. Each year there are over 5,500 deaths and 65,000 injuries due to traffic accidents. For every 100 accidents, 11 people are killed, compared to 3 per 100 accidents in other European Union countries. The economic and social costs of disease are high. The direct costs alone are estimated at over D 4 billion annually, which constitutes 21% of the gross national product. Emergency medical care is 99% state-financed. It provides a nationwide service and is part of an integrated system which is closely related to and co-operates with the State Emergency Medical Care and Fire-fighting Services.1—4 Because of geographical and demographic diversity, as well as a diversity of threats in various provinces, there are regional differences in emergency medical services. Substantial differences are observed between the southern, western and central regions and the eastern and northern regions of the country. The main problems of the Mazovian Province, inhabited by over 5 million including the Warsaw conurbation (3 million) and the capital of the country (1.7 million), are traffic accidents and diseases of civilisation. There is an average 45.6 hospital beds per 10,000 inhabitants and 1842 patients/10,000 inhabitants are treated annually. There are 18 hospital emergency departments in this province. The highly industrialised and polluted Silesian Province with almost 4.7 million inhabitants and a mean population density of 380 persons/km2 has a high rate of traffic and industrial accidents. The average number of hospital beds is 57.1 per 10,000 inhabitants, the number of in-patients is 1805/10,000 inhabitants and the num-
W. Hladki et al. ber of medical consultations provided annually is 6.8 per inhabitant. There are 12 emergency departments in this province. The Malopolska Province (3.1 million) is a mainly mountainous area with a well developed industry and includes the Krakow conurbation (1.2 million inhabitants) and has average population density of 250 persons/1 km2 .1,5—8 It receives the greatest number of tourists annually, the majority of whom are from abroad. There are 22 emergency departments. These three provinces comprise the greatest number of emergency departments of all provinces in the country. There are some provinces with a lower number of inhabitants and lower population density, e.g. the Podlaskie Province (1.2 million inhabitants) and population density of 59.4 persons/km2 where there are fewer challenges for the emergency medical service and therefore the number of emergency departments is proportionally smaller, 9.1 A first responder service based on ambulance teams, Helicopter Emergency Medical Services and emergency departments has been functioning since the end of the World War II in co-operation with the State Fire-fighting Service. In 1995 the State Emergency Care and Fire-fighting System (SECAFS) was created, the aim of which was to standardise the rescue functions formerly carried out by the State Fire-fighting Service. The SECAFS coordinates the fire-fighting and rescue functions at sites of catastrophes and natural disasters in co-operation with technical, ecological and medical emergency services in all Polish counties and provinces. The state emergency care system constitutes an integral part of the countries security system. The SECAFS includes 508 emergency care and fire-fighting centres and 3433 voluntary fire brigades. Currently all fire-fighters are licensed paramedics. The State Emergency Care and Fire-fighting Service comprises 11 hospitals, 10 of which are owned by the Ministry of Interior Affairs and Administration (in Warszawa, Krak´ ow, Pozna´ n, Ł´ od´z, Olsztyn, Katowice, Białystok, Lublin, Szczecin and Wrocław) and the Burns Treatment Centre in Siemianowice ´ Sl˛ askie. The SECAFS also includes the Marine Search and Rescue Service, Mining Rescue Service, Police, Emergency Medical Service, Border Guard, State Inspection of Environment Protection, State Atomic Physics Agency, Institute of Meteorology and Water Exploitation, as well as extra-governmental organisations, such as Volunteer Mountain Search and Rescue Service, Volunteer Water Rescue Service, Volunteer Tatra Rescue Service, Polish Aero-club, Association of Polish Scouts, Polish Medical Mission and the Polish Red Cross.3,4
Emergency medicine in Poland In 1999 the formation of a uniform, integrated and modern Polish emergency medial care system was begun to improve the rescue service under SECAFS guidelines. The main aims of this new service were improvement of emergency patient transport, decrease in death rates during the prehospital phase of care and reducing the time between scene and arrival at an appropriate health care facility. The main areas that required immediate and effective improvement were: pre-hospital care, integration of emergency medical services with other emergency subjects, hospital emergency care and education in the field of emergency medicine.2,9,10 The first stage of the Ministry of Health programme was called ‘‘Integrated Emergency Care’’ and was completed in the years 1999—2002. It was state-financed and based on the State Emergency Medical Care Act passed on July 25th 2001, the socalled ‘‘Mother Act’’ and the government executive orders passed in the years 2002—2005. The programme targets that were achieved by December 30th 2004 included: 1. Provision of an adequate number of ambulances to attend the injured/sick within 9 min within the city and 15 min outside the city in at least 50% of cases. These targets were set by the Medical Emergency Act and required a total of 1140 ambulances for the whole country.11,12 2. Creation of 130 dispatch centres to ensure effective ambulance dispatch. 3. Building 278 emergency departments (1 hospital emergency department per 150,000 inhabitants and 16 paediatric emergency departments). After the requirement for personnel educated in emergency medicine was recognised 2000 specialty training posts in emergency medicine for doctors were created, and emergency medicine soon became a the basic medical specialty in Poland. Originally, this kind of specialty training was done, within a ‘‘shortened specialty pathway’’, by specialists in other medical fields, such as, anaesthesiology and intensive therapy, general surgery, internal medicine and paediatrics. The first specialty training in emergency medicine was completed in 2003. The duration of specialty training in emergency medicine is now 5 years. Since 2002, undergraduate courses have been run for paramedics in medical universities and colleges. Also undergraduate studies in the field of emergency medicine are conducted in eight state medical universities. Moreover, students of the medical faculty have to undergo a compulsory emergency medicine training finishing with an examination held in the last year of the 6-
215 year medical studies. Nurses can also specialise in emergency medicine during a 2-year specialty training followed by a special state examination. Courses are also used to educate dispatchers. The Polish Resuscitation Council (founded in 2001, http://www.prc.krakow.pl) and the Polish Emergency Medicine Association play an important role in specialty courses and training in emergency medicine for doctors. Certified courses in BLS/AED, ILS, ALS, EPLS, BTLS, PALS and ATLS are available. These organisations also contribute to trainings in first aid for various professional groups: e.g. teachers, policemen, firemen, flight attendants, security guards, etc. International Championships in Emergency Medical Care and Road Rescue are organised annually in Poland providing opportunities to improve rescue skills.
Pre-hospital care Pre-hospital medical care in Poland consists of various components of an integrated emergency medical care system including dispatch centres, rescue teams, Helicopter Emergency Medical Service and fire brigades. Dispatch centres belong to the State Emergency Care and Fire-fighting System. The main duty of the dispatch centres is receiving emergency calls (phone numbers are 999, 998, 112), assessment of the received information and the dispatch of an emergency service team to the scene. Currently telephone calls to 112 are re-routed by the police to the despatch centre. Dispatch centres frequently include fire brigade controllers and emergency medical service controllers. In Poland there are a total of 155 dispatch centres which exceeds the number originally projected.2,13,14 The ambulance service is provided by the emergency medical service and provides trained rescue teams. The Polish emergency medical service includes several types of ambulance vehicles distinguished by letters painted on the vehicle body.15,16 Resuscitation ambulances (R) are used in life threatening conditions. The ambulance rescue team consists of a doctor (a specialist in emergency medicine, an anaesthesiologist or an internist on a specialty training programme in emergency medicine), a paramedic, emergency nurse or two paramedics and an ambulance driver. Accident ambulances (W), also called primary ambulances are dispatched where a resuscitation ambulance is not necessary or where there is no ‘‘R’’ team available. The equipment on the ‘‘R’’ and ‘‘W’’ ambulances are almost identical. A ‘‘W’’ ambulance team usually consists of a doctor and an
216 emergency nurse or paramedic who are licensed to perform rescue interventions. The team of a ‘‘W’’ ambulance may not include a doctor, and one of the rescue team members possessing a driving licence for priority vehicles can drive the ambulance. If none of the team members has got such a licence, a vehicle driver has to be included to the team. Transport ambulances (P), used for the transport of patients not requiring pre-hospital intensive care or blood transfusion, comprise a driver and a paramedic. From 2007 transport ambulance teams can work with a paramedic and without a doctor. These ambulances are not included in the integrated emergency medical service, but in hospital emergency departments.17 Neonatal ambulances (N), are used for transport of neonates and infants. Generally, ambulances are stationed in ambulance bases collocated with hospital emergency departments, in ambulance stations outside hospitals and in fire-fighting units. In Poland about 1400 ambulances are contracted to provide the emergency medical service, which meets the country’s requirements. The mean response times in rural and urban areas are close to the norms accepted in the European Union. Krak´ ow has one of the oldest civil municipal ambulance stations in the world (the third after Vienna and Budapest) founded in 1891. The Helicopter Emergency Medical Service is a separate public health care unit subordinate to the Minister of Health, providing an emergency medical service and transport.13,18,19 Presently, Helicopter Emergency Medical Services include 16 permanent bases, 2 seasonal bases in the Pomeranian and Mazurian regions working only in summer (18 Mi-2plus helicopters). Apart from the Helicopter Emergency Medical Service, in the Tatra Mountains, a W3A ‘‘Sok´ oł’’ helicopter belonging to the Voluntary Tatra Mountains Search and Rescue service is used. The area of activities of the Helicopter Emergency Medical Service includes the majority of the country territory. The equipment and personnel of the helicopters are similar to those of the resuscitation ambulances. They are used to aid overloaded ambulance medical teams or for cases requiring immediate transport of the injured to a special hospital facility. Rescue activities are performed by Mi-2plus helicopters and transport is ensured by Augusta A109E Power helicopters and Piaggio P-118 Avanti and PZL M-Mewa aeroplanes. By 2010, the purchase of 23 new helicopters and one flight simulator is planned. In some big cities in Poland there are also motor cycle emergency medical services with a paramedic. Occasionally, rescue boats including motorboats are used for emergency transport by water. The work of rescue teams is financed from the state budget.
W. Hladki et al.
Emergency department Emergency departments are another element of the integrated emergency medical care system in Poland. At present there are 150 medical departments. They are situated in hospitals which where it is mandatory to have an intensive therapy unit, general surgery and trauma surgery departments, an internal medicine department, radiology department and diagnostic laboratories. They may also contain departments of cardiology, paediatrics, neurology, gynaecology and obstetrics, dialysis unit and a landing field for helicopters but this is not mandatory. In Poland, the tasks of the emergency departments are: stabilisation of the patient’s condition, initial diagnosis and treatment of a wide range of acute cases, poisoning and major injuries. Generally, emergency departments deal with patients who are brought by emergency teams and the also those who report to the hospital by themselves. The care for mass casualties is provided according to county or provincial guidelines for emergency medical services. Other tasks of the emergency departments include collection and storage of documentation and supervision and assessment of the activities of the units of the integrated emergency medical services in the catchment area of the emergency departments.7,8,13,20—23 The emergency departments in certain major hospitals are accredited to conduct training and courses in emergency medicine. Currently, there are 32 such emergency departments but the ultimate number proposed by the Ministry of Health is 118. Each emergency department has to contain all necessary areas including an assessment area, observation, shortterm intensive therapy, resuscitation, surgery, consultation, diagnostics and laboratories. In the last 7 years a large sum of money has been spent to equip the emergency departments with emergency equipment in accordance with the State Emergency Medical Care Act and European Union standard guidelines. The staff working in the emergency departments consist of emergency physicians, doctors on specialty training in emergency medicine, anaesthesiology, internal medicine, general and trauma surgery and specialists in other medical disciplines. Approximately 100 patients are admitted to the emergency departments daily. The survey conducted on March 1st 2007 in Poland showed a total of 458 emergency physicians and 465 doctors undertaking specialty training in emergency medicine. The emergency departments also employ paramedics and emergency nurses. In 2006 the first specialisation exam in emergency nursing was organised for 115 nurses. There is still a short-
Emergency medicine in Poland age of emergency departments in Polish hospitals. To ensure full emergency medical care, about 100 more emergency departments will be required. For example, Mazovian province has a deficiency of 10 emergency departments, Silesian province 14 and Podlaskie province 4. In these provinces, admission rooms serve as a substitute for the missing emergency departments. Only Malopolska Province has the required number of emergency departments. Hospital emergency departments are financed by the State Health Fund. During a short, 10-year period of development of a modern emergency medical care system in Poland many problems have been encountered including getting emergency medicine recognised as a specialty, financial problems and meeting high local demands and expectations. Considerable progress has been made in building an integrated, modern emergency care system. In some provinces emergency medical services fully meet the inhabitants’ needs in emergency medical care in terms of numbers of ambulances and dispatch centres. In the next 2—3 years the remaining emergency departments are to be completed; work has already commenced. Moreover, a network of highly specialised life-rescue centres is being formed (centres for trauma, stroke, burns, poisoning and interventional cardiology) for the purpose of improving the effectiveness of emergency services in Poland. The Act of the State Emergency Care, which was passed on 1st January 2007 regulates the emergency service system and assures the financial support of the emergency departments. The Act makes the provincial governors responsible for the activity of local emergency medical services. It allows the use of staffed ambulances without doctors, only with paramedics who are licensed to perform a wide range of rescue procedures. The Act was formed on the basis of ‘‘Mother Act’’ about the State Emergency Care System from 2001.17,18 Currently, the most urgent problems to solve are: (1) the separation of the tasks of primary medical care and family medicine from the tasks of emergency medical care; (2) the increase in the number of emergency departments to 250; (3) the assurance of appropriate funding of emergency departments both for the operational readiness financed from the state budget and for the performance of medical procedures financed from the National Health Fund; (4) the increase in the number of accredited training departments to 118 to ensure an adequate number of training opportunities in emergency medicine; (5) the increase in the number of doctors (by 600) admitted for specialty training in emergency medicine; (6) education of a total number of 4500—5000 specialists in
217 emergency medicine working for emergency medical service; (7) providing continuous education and supplementary courses in emergency medicine for nurses and paramedics; (8) improvement of the professional competence of nurses, paramedics and dispatchers by creation of in-service obligatory courses for them (one every 5 years); (9) standardisation of the curriculum for undergraduate education. It should be pointed out that in most developed countries the formation of a modern emergency system took considerable time (approximately 20 years). During this period it was impossible to avoid making mistakes, and because of its specificity, the emergency medical service is still not perfect. The greatest potential for emergency medical care in Poland lies in its people, their knowledge, enthusiasm, willingness for further education and unshakable belief in final success. The basis for the activities of the state emergency system is the Polish Association of Emergency Medicine, the Polish Council of Resuscitation and the Polish Government with its agencies. The greatest problem of emergency medical service system in Poland is the limited financial resources available.
Conflict of interest None.
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