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Prehospital Emergency Care in Hungary: What Can We Learn from the Past?
The Journal of Emergency Medicine, Vol. 39, No. 4, pp. 512–518, 2010 Copyright © 2010 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter
doi:10.1016/j.jemermed.2009.09.029
International Emergency Medicine
PREHOSPITAL EMERGENCY CARE IN HUNGARY: WHAT CAN WE LEARN FROM THE PAST? Zsigmond Gondocs, MD,* Andras Olah, RN, MNS, PHD,† Jozsef Marton-Simora, RN, MNS,† Gabor Nagy, MD,† Juergen Schaefer, EMT,‡ and Jozsef Betlehem, RN, MNS, MED, PHD† *Hungarian National Ambulance Service, Budapest, Hungary, †Faculty of Health Sciences, University of Pecs, Pecs, Hungary and ‡Bethanien Hospital, Frankfurter Diakonie Clinics, Frankfurt am Main, Germany Reprint Address: Jozsef Betlehem RN, MNS, MED, EMT, PhD, Faculty of Health Sciences, University of Pecs, Vorosmarty u. 4, H-7621 Pecs, Baranya, Hungary
tion for non-acute illnesses have been introduced, allowing the National Ambulance Service to concentrate on emergencies only. Conclusions: Although the Hungarian Ambulance Service has a very long and meaningful past and a respected professional development, new challenges facing prehospital emergency care are inevitable and continuous development is necessary. © 2010 Elsevier Inc.
e Abstract—Background: In Hungary, prehospital emergency medical services are provided by the National Ambulance Service. The 60th anniversary of the National Ambulance Service provides a good opportunity to give an overview of the current trends in prehospital emergency medical care in Hungary. Objectives: In this report, a description of the organizational structure and the latest developments in the National Ambulance Service are described with the intention to highlight future directions in emergency medical services, as well as the influence of international trends in emergency patient care. Results: In Hungary, the ambulance cars are staffed by two or three crew members trained in rescue, stabilization of the patient’s status, transport, and advanced care of traumatic and medical emergencies. There are three major levels of care provided by ambulance personnel: a basic level ambulance crew (Emergency Medical Technician Unit), a second level (Ambulance Officer Unit), and the highest level (Emergency Physician Unit). The personnel on the latter two units are trained in all aspects of Basic Life Support and Advanced Life Support procedures for prehospital emergency care. Following the latest international developments in medical rescue devices and guidelines, all staff are retrained yearly. Recently, private services for transporta-
e Keywords— emergency medical services; Hungary; ambulance; prehospital care; training
INTRODUCTION Since the collapse of the socialistic regime in Central and Eastern Europe, there has been a surge in new developments in the sciences. Emergency medical care has been given a new identity, although prehospital emergency medical care has a long history in Hungary. The origin of organized Hungarian prehospital emergency care goes back to the second half of the 19th century. The first governmental decree on organized rescue in Hungary was issued in 1876. Under the auspices of the Ministry of the Interior, the first organized Budapest Voluntary Ambulance Society was founded on May 10, 1887 in Budapest. Before that, in 1882, rescue on the railway had already begun through the development of a rescue wagon for the order of the Royal Railway of the Austro-
This article aims to show the current situation of prehospital emergency medical care in Hungary at the 60th anniversary of the National Ambulance Service. This might be of interest to emergency care providers and experts.
RECEIVED: 12 April 2009; FINAL ACCEPTED: 27 September 2009
SUBMISSION RECEIVED:
4 August 2009; 512
Prehospital Emergency Care in Hungary
Hungarian Empire (1). Later, Dr. Geza Kresz, founder of organized Hungarian rescue, fostered the establishment of more rescue stations in the countryside, in addition to the capitol station in Budapest, with each rescue station either joining with the local fire department or forming a separate entity (2). In 1926, the National Ambulance Society of the Hungarian Cities and Counties was founded, involving six stations countrywide. Vehicles for patient transport were added with the advent of automobile production around the turn of the 20th century. In 1902, the first Dyon 3.5 LE automobile was introduced, to carry ambulance personnel to the scene, and since 1909 it has been possible to transport a patient with a motor vehicle (Berliet 22 LE) (3). After World War II, on May 10, 1948, the National Ambulance Service was founded by the new political regime in Hungary, and since then it has been responsible for emergency medical rescue and transportation all over the country (4). During the epoch of socialism, further professional development took place, and the first emergency physician car (named ROKO) was introduced in 1954. ROKO enabled the transport of a small intensive care unit to the scene, including an emergency physician, an emergency medical technician (EMT), and a driver. Once a patient was stabilized, it was possible to transfer the patient to the dedicated hospital for further treatment. In 1956, during the Hungarian Revolution, the Ambulance Hospital was opened in Budapest to care for injured and ill patients. This was the first 24-hour emergency hospital in Hungary (5). After the political change in 1989, the legislation allowed other non-governmental organizations such as St. Johns, Malteser, Arbeiter Samariter, and Falck to participate in patient transport, and later, in some cases, in emergency rescue, under the direction of the National Ambulance Service. In the past decades, the slow development of the specialty of Emergency Medicine and the proliferation of emergency departments (EDs) in hospitals has strengthened the evolution of a highly skilled and well-equipped ambulance service that provides emergency medical care at the site of an accident. Beginning in 2007, patient transport and emergency medical services were separated and now, after long decades, the Hungarian National Ambulance Service handles only emergency cases.
OVERVIEW OF THE HEALTH CARE SYSTEM IN HUNGARY Hungary is located in Central Europe, internationally bordered by Slovakia to the north, Ukraine and Romania to the east, Serbia and Croatia to the south, and Slovenia and Austria to the west. Hungary has a population of about 10 million people living in an area of 93,000
513
square km and consisting of seven regions (19 counties). About 2 million people live in Budapest, the capital of Hungary. The population of the other major cities is far less, each being somewhere between 100,000 and 200,000 inhabitants. The density of the population is 108 per square km (6). The birth rate was among the lowest in Europe at 9.7 per thousand inhabitants in 2007. In the same year, the average life expectancy at birth was 73.2 years (69 years for men and 77.4 years for women). The total expenditure of the National Health Insurance Fund was 5.6 billion Euros in 2007, 46% of which was for curative and preventive health care and subsidies on medicaments and devices. The natural decrease in the population was 35,200 in 2007, similar to other Western European countries. The aging of the population has accelerated in recent years (7). Admission to hospitals due to urgent causes has increased by ⬍ 3%, from 648,045 cases in 2000 to 664,773 cases in 2007. The number of urgent patients did not vary much in the past 7 years, but in patient transport, a huge reduction was detectable in 2007 due to the appearance of other patient transport provider companies. The regular non-urgent patient transport, as directed by the new legislation, has decreased by 65%, from 2,072,356 cases in 2000 to 730,856 cases in 2007. The new governmental decree has taken non-urgent patient transport away from the main duties of the National Ambulance Service (Table 1). Statistics from the National Ambulance Service shows an increase (14%) in overall emergencies between 2000 and 2007. Similar to other countries in Europe, the main mechanism of injury resulting in the need for emergency medical services in 2007 was accidents, occurring most frequently in domestic areas (59%), followed by public
Table 1. The Duties of the Hungarian National Ambulance Service, 2000 –2007, by Priority Category Type of Duties Year
Urgent Care*
Transport†
Preparedness‡
2000 2001 2002 2003 2004 2005 2006 2007
648,045 649,971 659,550 677,554 665,492 679,020 673,576 664,773
2,072,356 2,038,444 2,072,871 2,058,539 1,860,290 1,568,021 1,259,871 730,856
3412 3421 3668 3768 3110 2245 2422 2574
* Urgent care: immediate emergency medical response after the call (in 1–2 min, the crew leaves the station). † Transport: regular non-urgent patient transport for minor risk patients, for example, from the patient’s home to an outpatient clinic for treatment. ‡ Preparedness: emergency medical high-risk transport from a general hospital to a specialized hospital for further treatment or for a special diagnostic procedure, during which an intervention might be needed.
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Table 2. The Main Locations of Accidents in Hungary between 2000 and 2007 Location of Accidents Year
Traffic
Industry
Agriculture
Domestic
Sport
Public Areas
Total
2000 2001 2002 2003 2004 2005 2006 2007
29,757 31,607 34,056 34,912 36,030 35,060 35,258 35,861
7213 6665 6530 6647 6736 6370 6200 5975
411 402 354 337 339 317 275 220
209,854 215,101 217,387 227,517 229,421 239,651 240,184 239,405
3423 3388 3436 3471 3446 3559 3494 3518
105,730 105,439 109,418 114,929 118,366 125,407 128,004 121,836
356,388 362,602 371,181 387,813 394,338 410,364 413,415 406,815
locations (30%) and traffic accidents (9%) (Table 2) (8 –10). The 160 Hungarian hospitals are organized into three categories. There are 31 specialized hospitals with 24-h emergency wards and facilities to care for the most acute cases. Patients do not have to travel more than 50 km from home to reach such a center. Regional hospitals for more minor operations, as well as the rehabilitation of patients, are situated closer to people’s homes, with the availability of one within 30 km of each person’s home. Hospital beds numbered 45,000 in acute wards and 27,000 in chronic wards in 2007. Outpatient centers care for residents within a 20-km radius. In recent years, the emergency services have been upgraded to respond to a call anywhere within 15 min. Emergency care in Hungary is free of charge for residents and visitors and is financed by the compulsory National Health Insurance Fund and by the Government (for citizens without health insurance). The Hungarian health care system has three political and administrative levels: National, County, and Municipal. The Ministry of Health is responsible for health policy, for the national health care institutions, and for the National Ambulance Service. The county chief physician and municipality chief physician are responsible for administration of the health care management in their respective domains. All of the health care institutions are divided into three levels according to the services they provide: tertiary, secondary, or primary. Primary care is provided by family physicians, pediatricians, and dentists; secondary care is provided in hospitals and outpatients clinics; and tertiary care is provided at national hospitals and university clinics by specialists. Emergency medical services (EMS) in Hungary are divided into two parts: prehospital care and in-hospital treatment. Prehospital treatment and transportation is delivered by the ambulance services, and the emergency intramural care by different levels of EDs in the hospitals. They are categorized according to the pro-
vided care, into ED1 (Emergency Center) and ED2 (Emergency Department) (11).
PREHOSPITAL EMERGENCY CARE IN HUNGARY Access to EMS Patients who become seriously ill or injured in the community usually will be treated and conveyed to hospital by one of the units of the National Ambulance Service. In an emergency, ambulances are accessed by dialing the common national access number 104 (or 112 for a general emergency call). When the incident location has been established, ambulance services are mobilized and further clinical information is relayed by TETRA (Terrestrial Trunked Radio) digital technology from dispatch room staff in 19 regional dispatch centers. Ambulance cars are in constant contact with the dispatch centers by TETRA systems and controlled by AVL (Auto Vehicle Location) terminals. TETRA terminals are also used to record routine ambulance service activity (e.g., velocity of ambulance cars, status of arrival and departure, usage of blue lights), thus freeing up radio time for transmission of other essential information (e.g., clinical details). The response time is used by the government as an important performance indicator for Hungarian ambulance services. Priority dispatch is used by ambulance services in prioritizing emergency calls. It is suggested that the average ambulance response time should be 15 min for the majority of the population. This standard is met in urban areas, but this is difficult to achieve in rural areas. Patient information is passed to the dispatch center, but usually ambulance teams transfer patients to the nearest hospital with an ED. The priority categories are the following: immediate response; response within 2 h; patient transport in rescue preparedness over 2 h (12).
Prehospital Emergency Care in Hungary
Types of Ambulance Units and Training of Personnel In Hungary, one of the main goals of the National Ambulance Service since its beginning has always been to keep the ambulance cars, equipment, and the educational background of the crew unified. To reach this goal, all functions and regulations are centralized, establishing in Hungary a unique ambulance service model. The FrancoGerman model had a great impact on its development. The educational background of the personnel on the ambulances is provided by different types of education. EMTs are trained in health care vocational schools in many cities within the country. Degree programs are offered for ambulance officers at three faculties of health sciences at universities, and medical programs are run by four medical universities with a later possibility of specialization in Emergency Medicine (13). The same protocols are used by the ambulance services all over the country, and are based on the latest developments in the medical sciences.
Ground Rescue Currently, ground rescue is based at 229 ambulance stations throughout Hungary. There are three main levels of ambulance units and other auxiliary vehicles (e.g., motor bike, Mobile Intensive Care Unit, Neonatal Emergency Physician Unit, Mass Casualty Incidents Unit). The basic units are staffed by an EMT (in Hungary called ambulance nurse) and a car driver. The cars are equipped with the most important devices for Basic Life Support (bandages, splints, vacuum mattress, rigid collar [Stifneck®; Laerdal Medical, Wappingers Falls, NY], oxygen cylinder, ventilation bag, suctioning device, oropharyngeal tubes, means of intravenous [i.v.] access, medications for oral use and inhalation). The majority of the cars are also equipped with an Automatic External Defibrillator. EMTs are trained in a 2-year course in one of the institutions for health care vocational education. The entry requirement for the diploma course is a General Certificate of Secondary Education (GCSE) and a minimum of 18 years of age. The core content of this course is developed and approved centrally by the Ministry of Health. Half of the training is hospital and emergency services based. The diploma must be registered by the Ministry of Health. The immediate care skills that can be performed by an EMT are the following: basic resuscitation procedures (basic life support, oxygen administration, oral and nasal airway adjuncts, bag-valve-mask ventilation, laryngeal mask airway, semiautomatic and manual defibrillation); hemorrhage control and wound care; fracture management; spinal injury care and immo-
515
bilization techniques; analgesia with inhaled Entonox; management of respiratory emergencies; basic physiological measurements; preparing transport position and fixation; administration of therapeutic drugs (Table 3); performing 12-lead electrocardiography; and supporting paramedics delivering advanced medical care. Car drivers are given shorter-term in-service training in Basic Life Support interventions. The next more advanced ambulances are Ambulance Officer Units staffed by an ambulance officer, an EMT, and a car driver. The cars are equipped with instruments for Advanced Life Support (ALS) including an electrocardiography monitor, defibrillator, intubation equipment, pulse oximeter, i.v. fluid therapy, gastric lavage supplies, perfuser, baby set, scoop stretcher, and a broad range of drugs. Ambulance officer training comprises 4 years of fulltime or part-time degree studies (BSC) in one of the faculties of Health Sciences of the three Universities that run the medical faculties. The course of study, besides the theoretical lessons, requires almost 50% of the time to be on-site practice in different teaching hospitals and emergency facilities. Ambulance officers gain experience, in addition to the EMT skills, in ALS interventions, trauma care, medical emergencies, triage, disaster management, and other emergency procedures. The entry requirements for the ambulance officers’ program are a GCSE and, in the case of part-time studies, 2 years of serving as an EMT. Basic skills above the EMT level are the following: endotracheal intubation; needle thoracocentesis; needle cricothyrotomy; i.v. cannulation; transthoracic pacemaker; i.v. analgesia; and oral, intramuscular, and i.v. drug administration (Table 3). The most advanced ambulances are the Emergency Physician Cars. These are staffed by emergency physicians in addition to an EMT and a car driver. These cars are equipped with all the important devices and medications needed for prehospital emergency medical care, including respirator and endocavital pacemaker facility. Emergency physicians are trained in the most advanced field interventions, including cardioversion, ventilation, anesthesia, and others. Emergency medical education is 3 years of further study to specialize in Emergency Medicine. This can be gained at one of the four medical universities. All members of the staffs of all levels are required to take part in refresher courses yearly. The rendezvous system exists in some cities, where the physician arrives on the scene in a rapid response car with all necessary equipment, but there are no facilities for patient transport. This system seems to be more flexible in some cases. The above-mentioned auxiliary ground vehicles are available in only some regions of Hungary, depending on the needs of the area.
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Table 3. Medication Usage by Ambulance Staff in Hungary in 2008 Medication Usage by Emergency Personnel in Hungary Personnel Name of the Drug
Emergency Medical Technician
Ambulance Officer
Emergency Physician
Tbl Tensiomin Pulv Carbo Medicinalis Tbl Aspirin Tbl Plavix Pulv Natrium hydrocarbonicum
X X X — X
X X X X X
X X X X X
Nitrolingual aerosol Berotec aerosol Sol. Berodual Ventolin Evohaler
X X X X
X X X X
X X X X
Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj
Algopyrin Diclofenac Fentanyl Morphinum-HCL Calypsol Lidocaine 1% Etomidat-Lipuro Propofol 1% Adenocor Betaloc Cordarone Magnesium Sulphuricum Verapamil Epanutin Anexate Naloxone Ebrantil Fenistil Suprastin Cerucal Haloperidol Theospirex Metilprednisolon Solu-medrol Furosemide Nitro-Pohl Midazolam Torex Seduxen Dobutamine Dopamine Tonogen Atropinum sulph. No-spa Heparibene Na Metalyse Oxytocin Glucagen
X — — — — — — — — — — — — — — — — — — — — — — — — — — — — — X X X — — — X
X X X X X X — — X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Inj Inj Inj Inj
Calcimusc Kalium Chloratum Na-hydrogencarbonat Sodium Chloride 0,9%
— — — X
X X X
X X X X
Supp. Nurofen Supp. Rectodelt Sol. Diazepam desitin
X X X
X X X
X X X
Glucosum 20% Hyperhaes 6% Isodex
X — —
X X X
X X X
Main Indication of Drug Per os medication Antihypertensives Absorbents Platelet aggregation inhibitor Laxatives Sublingual or buccal medication Glyceryl TriNitrate Sympathomimetics i.m., i.v. Medications Analgesics
Anesthetics
Antidysrhythmics
Anticonvulsive Antidotum Antihypertensives Antihistamines Antiemetics Antipsychotics Broncho-spasmolitics Corticosteroids Diuretics Nitroglycerin Sedatives Sympathomimetics Parasympatholytics Spasmolytics Thrombolytics Uterotonicum Glucagon Others
Rectal Analgesics Corticosteroids Sedatives Infusions
Prehospital Emergency Care in Hungary
517
Table 3. (Continued) Medication Usage by Emergency Personnel in Hungary Personnel Main Indication of Drug
Gases Oxygen Entonox
Emergency Medical Technician
Ambulance Officer
Emergency Physician
Ringer fundin Ringer’s lactate Voluven 6%
X X —
X X X
X X X
Oxygen Nitralgin
X X
X X
X X
Name of the Drug
Inj ⫽ injection; Pulv ⫽ pulvis; Sol ⫽ solution; Supp ⫽ suppository; Tbl ⫽ tablet.
The brands of ambulance cars used are the following: EMT unit, Toyota Hiace and Ford Transit 2.0 TDC 300; Ambulance Officer Unit, Mercedes Sprinter; and Emergency Physician, Mercedes Sprinter.
Air Rescue Ground rescue is augmented by air ambulances. Helicopter rescue is restricted to high-priority rescue in the country. There are seven regions in Hungary (districts of Balatonfüred, Budapest, Debrecen, Miskolc, Pécs, Sármellék, and Szentes) that have an air ambulance rescue system. In case of need they also provide inter-hospital transports. Ambulance flights are restricted to daytime hours. For long-distance transportation (repatriation), there is also an ambulance plane facility available. All air ambulances are equipped with the devices of a Mobile Intensive Care Unit, but an additional Propaq monitoring system is also available onboard. Water rescue and other special rescue, for example, mountain rescue and cave rescue, are provided by different non-governmental organizations. The Hungarian National Ambulance Service is still the most powerful organization, with 5774 personnel providing prehospital emergency care in Hungary (Table 4). In recent years, continuous quality improvement has been introduced in the service to standardize all the procedures related to prehospital emergency medical care.
FUTURE DIRECTIONS IN EMERGENCY CARE IN HUNGARY The Hungarian prehospital emergency medical care service plays an essential role in Hungarian emergency care. The standardized protocols used by the Hungarian National Ambulance Services personnel are identical to the
guidelines developed by international professional bodies. To further ensure consistency and quality in the EMS system and to narrow the gap between prehospital and intramural patient care, the staff is involved in continuous medical education. Based on its organizational origins, a “stay and play” philosophy still characterizes prehospital care in Hungary and no doubt will continue. An Emergency Medical System is rapidly evolving in Hungary at a time of rapid change. The current Hungarian EMS system is highly efficient and provides sophisticated prehospital treatment to acutely ill patients and trauma victims. However, recent developments challenge the system. There is strong evidence that early specific treatment at the scene improves the victim’s outcome. However, this requires a highly qualified, unified professional team. Unfavorable working conditions have caused minor recruitment problems. Also, the number of hospitals in Hungary is being reduced, and patient transport and prehospital medical emergency care are being separated as a result of the Government’s initiative to cut health care costs. The combined effect is that the number of ambulance cars at times may not be adequate, and emergency transport time may be increased. Histor-
Table 4. Distribution of Ambulance Staff by Role, at the National Ambulance Service in Hungary 2000 –2007 Type of Personnel Year
Emergency Physician
Ambulance Officer
EMT
Car Driver
2000 2001 2002 2003 2004 2005 2006 2007
151 177 180 172 190 136 135 125
342 339 374 413 519 491 462 519
2862 2972 3062 3131 3256 2980 2620 2738
2392 2493 2522 2600 2614 2572 2431 2392
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Z. Gondocs et al.
ically, the bulk of this care has been delivered by the state, and this is likely to continue to be the case for the foreseeable future. The development of regional hospitals with resources to manage complex illnesses and injuries throughout Hungary could significantly enhance the standards of prehospital emergency care delivered by the National Ambulance Service. Timely patient access to such centers is likely to remain a significant challenge. Further investment and development in prehospital emergency care networks could improve patient access to emergency care. REFERENCES 1. Felkai T. The establishment of rescue on the rails (A vasúti mentés kialakulása) [Hungarian]. Health at Railways (Vasútegészségügy) 1974;2-3:123. 2. Papp Z. The prominence of the Hungarian rescue (A magyar menetésügy kiemelkedö személyiségei) [Hungarian]. Journal of the Hungarian Society of Emergency Medicine (Magyar Mentesügy) 2001;21:62– 4. 3. Debrodi G. Rescue on the rails (1882–1931) [Hungarian]. Orvostort Kozl 2006;51:147– 64.
4. Felkai T. The history of the Hungarian rescue, book of anniversary (Magyar Mentéstörténet, Jubileumi Emlékkönyv) [Hungarian]. Budapest, Hungary; 1987:27– 45. 5. Maklary L. The ambulance hospital (Mentokorhaz) [Hungarian]. Journal of the Hungarian Society of Emergency Medicine (Magyar Mentésügy) 2004;24:150 – 61. 6. Hungary in Figures 2007. Budapest: Hungarian Statistical Office; 2008. 7. Hungarian Statistical Yearbook. Budapest: Hungarian Statistical Office; 2007. 8. Langhelle A, Lossius HM, Silfvast T, et al. International EMS systems: the Nordic countries. Resuscitation 2004;61:9 –21. 9. Black JMJ, Davies DG. International EMS systems: United Kingdom. Resuscitation 2005;64:21–9. 10. Roessler M, Zuzan O. EMS system in Germany. Resuscitation 2006;68:45–9. 11. Ministry of Health, Social Welfare and Family. Decree No. 60/ 2003. (X. 20). On the minimum standards of providing health care services [Hungarian]. (ESzCsM rendelet az egészségügyi szolgáltatások nyújtásához szükséges szakmai minimumfeltételekröl). Budapest, Hungary: Ministry of Health; 2003. 12. Ministry of Health. Decree NO. 5/2006 (II. 7). On medical rescue [Hungarian]. (EüM rendelet a mentésröl). Budapest, Hungary: Ministry of Health; 2006. 13. Betlehem J, Kukla A, Deutsch K, Marton-Simora J, Nagy G. The changing face of European healthcare education: the Hungarian experience. Nurse Educ Today 2009;29:240 –5.
doi:10.1016/j.jemermed.2009.09.029
International Emergency Medicine
PREHOSPITAL EMERGENCY CARE IN HUNGARY: WHAT CAN WE LEARN FROM THE PAST? Zsigmond Gondocs, MD,* Andras Olah, RN, MNS, PHD,† Jozsef Marton-Simora, RN, MNS,† Gabor Nagy, MD,† Juergen Schaefer, EMT,‡ and Jozsef Betlehem, RN, MNS, MED, PHD† *Hungarian National Ambulance Service, Budapest, Hungary, †Faculty of Health Sciences, University of Pecs, Pecs, Hungary and ‡Bethanien Hospital, Frankfurter Diakonie Clinics, Frankfurt am Main, Germany Reprint Address: Jozsef Betlehem RN, MNS, MED, EMT, PhD, Faculty of Health Sciences, University of Pecs, Vorosmarty u. 4, H-7621 Pecs, Baranya, Hungary
tion for non-acute illnesses have been introduced, allowing the National Ambulance Service to concentrate on emergencies only. Conclusions: Although the Hungarian Ambulance Service has a very long and meaningful past and a respected professional development, new challenges facing prehospital emergency care are inevitable and continuous development is necessary. © 2010 Elsevier Inc.
e Abstract—Background: In Hungary, prehospital emergency medical services are provided by the National Ambulance Service. The 60th anniversary of the National Ambulance Service provides a good opportunity to give an overview of the current trends in prehospital emergency medical care in Hungary. Objectives: In this report, a description of the organizational structure and the latest developments in the National Ambulance Service are described with the intention to highlight future directions in emergency medical services, as well as the influence of international trends in emergency patient care. Results: In Hungary, the ambulance cars are staffed by two or three crew members trained in rescue, stabilization of the patient’s status, transport, and advanced care of traumatic and medical emergencies. There are three major levels of care provided by ambulance personnel: a basic level ambulance crew (Emergency Medical Technician Unit), a second level (Ambulance Officer Unit), and the highest level (Emergency Physician Unit). The personnel on the latter two units are trained in all aspects of Basic Life Support and Advanced Life Support procedures for prehospital emergency care. Following the latest international developments in medical rescue devices and guidelines, all staff are retrained yearly. Recently, private services for transporta-
e Keywords— emergency medical services; Hungary; ambulance; prehospital care; training
INTRODUCTION Since the collapse of the socialistic regime in Central and Eastern Europe, there has been a surge in new developments in the sciences. Emergency medical care has been given a new identity, although prehospital emergency medical care has a long history in Hungary. The origin of organized Hungarian prehospital emergency care goes back to the second half of the 19th century. The first governmental decree on organized rescue in Hungary was issued in 1876. Under the auspices of the Ministry of the Interior, the first organized Budapest Voluntary Ambulance Society was founded on May 10, 1887 in Budapest. Before that, in 1882, rescue on the railway had already begun through the development of a rescue wagon for the order of the Royal Railway of the Austro-
This article aims to show the current situation of prehospital emergency medical care in Hungary at the 60th anniversary of the National Ambulance Service. This might be of interest to emergency care providers and experts.
RECEIVED: 12 April 2009; FINAL ACCEPTED: 27 September 2009
SUBMISSION RECEIVED:
4 August 2009; 512
Prehospital Emergency Care in Hungary
Hungarian Empire (1). Later, Dr. Geza Kresz, founder of organized Hungarian rescue, fostered the establishment of more rescue stations in the countryside, in addition to the capitol station in Budapest, with each rescue station either joining with the local fire department or forming a separate entity (2). In 1926, the National Ambulance Society of the Hungarian Cities and Counties was founded, involving six stations countrywide. Vehicles for patient transport were added with the advent of automobile production around the turn of the 20th century. In 1902, the first Dyon 3.5 LE automobile was introduced, to carry ambulance personnel to the scene, and since 1909 it has been possible to transport a patient with a motor vehicle (Berliet 22 LE) (3). After World War II, on May 10, 1948, the National Ambulance Service was founded by the new political regime in Hungary, and since then it has been responsible for emergency medical rescue and transportation all over the country (4). During the epoch of socialism, further professional development took place, and the first emergency physician car (named ROKO) was introduced in 1954. ROKO enabled the transport of a small intensive care unit to the scene, including an emergency physician, an emergency medical technician (EMT), and a driver. Once a patient was stabilized, it was possible to transfer the patient to the dedicated hospital for further treatment. In 1956, during the Hungarian Revolution, the Ambulance Hospital was opened in Budapest to care for injured and ill patients. This was the first 24-hour emergency hospital in Hungary (5). After the political change in 1989, the legislation allowed other non-governmental organizations such as St. Johns, Malteser, Arbeiter Samariter, and Falck to participate in patient transport, and later, in some cases, in emergency rescue, under the direction of the National Ambulance Service. In the past decades, the slow development of the specialty of Emergency Medicine and the proliferation of emergency departments (EDs) in hospitals has strengthened the evolution of a highly skilled and well-equipped ambulance service that provides emergency medical care at the site of an accident. Beginning in 2007, patient transport and emergency medical services were separated and now, after long decades, the Hungarian National Ambulance Service handles only emergency cases.
OVERVIEW OF THE HEALTH CARE SYSTEM IN HUNGARY Hungary is located in Central Europe, internationally bordered by Slovakia to the north, Ukraine and Romania to the east, Serbia and Croatia to the south, and Slovenia and Austria to the west. Hungary has a population of about 10 million people living in an area of 93,000
513
square km and consisting of seven regions (19 counties). About 2 million people live in Budapest, the capital of Hungary. The population of the other major cities is far less, each being somewhere between 100,000 and 200,000 inhabitants. The density of the population is 108 per square km (6). The birth rate was among the lowest in Europe at 9.7 per thousand inhabitants in 2007. In the same year, the average life expectancy at birth was 73.2 years (69 years for men and 77.4 years for women). The total expenditure of the National Health Insurance Fund was 5.6 billion Euros in 2007, 46% of which was for curative and preventive health care and subsidies on medicaments and devices. The natural decrease in the population was 35,200 in 2007, similar to other Western European countries. The aging of the population has accelerated in recent years (7). Admission to hospitals due to urgent causes has increased by ⬍ 3%, from 648,045 cases in 2000 to 664,773 cases in 2007. The number of urgent patients did not vary much in the past 7 years, but in patient transport, a huge reduction was detectable in 2007 due to the appearance of other patient transport provider companies. The regular non-urgent patient transport, as directed by the new legislation, has decreased by 65%, from 2,072,356 cases in 2000 to 730,856 cases in 2007. The new governmental decree has taken non-urgent patient transport away from the main duties of the National Ambulance Service (Table 1). Statistics from the National Ambulance Service shows an increase (14%) in overall emergencies between 2000 and 2007. Similar to other countries in Europe, the main mechanism of injury resulting in the need for emergency medical services in 2007 was accidents, occurring most frequently in domestic areas (59%), followed by public
Table 1. The Duties of the Hungarian National Ambulance Service, 2000 –2007, by Priority Category Type of Duties Year
Urgent Care*
Transport†
Preparedness‡
2000 2001 2002 2003 2004 2005 2006 2007
648,045 649,971 659,550 677,554 665,492 679,020 673,576 664,773
2,072,356 2,038,444 2,072,871 2,058,539 1,860,290 1,568,021 1,259,871 730,856
3412 3421 3668 3768 3110 2245 2422 2574
* Urgent care: immediate emergency medical response after the call (in 1–2 min, the crew leaves the station). † Transport: regular non-urgent patient transport for minor risk patients, for example, from the patient’s home to an outpatient clinic for treatment. ‡ Preparedness: emergency medical high-risk transport from a general hospital to a specialized hospital for further treatment or for a special diagnostic procedure, during which an intervention might be needed.
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Table 2. The Main Locations of Accidents in Hungary between 2000 and 2007 Location of Accidents Year
Traffic
Industry
Agriculture
Domestic
Sport
Public Areas
Total
2000 2001 2002 2003 2004 2005 2006 2007
29,757 31,607 34,056 34,912 36,030 35,060 35,258 35,861
7213 6665 6530 6647 6736 6370 6200 5975
411 402 354 337 339 317 275 220
209,854 215,101 217,387 227,517 229,421 239,651 240,184 239,405
3423 3388 3436 3471 3446 3559 3494 3518
105,730 105,439 109,418 114,929 118,366 125,407 128,004 121,836
356,388 362,602 371,181 387,813 394,338 410,364 413,415 406,815
locations (30%) and traffic accidents (9%) (Table 2) (8 –10). The 160 Hungarian hospitals are organized into three categories. There are 31 specialized hospitals with 24-h emergency wards and facilities to care for the most acute cases. Patients do not have to travel more than 50 km from home to reach such a center. Regional hospitals for more minor operations, as well as the rehabilitation of patients, are situated closer to people’s homes, with the availability of one within 30 km of each person’s home. Hospital beds numbered 45,000 in acute wards and 27,000 in chronic wards in 2007. Outpatient centers care for residents within a 20-km radius. In recent years, the emergency services have been upgraded to respond to a call anywhere within 15 min. Emergency care in Hungary is free of charge for residents and visitors and is financed by the compulsory National Health Insurance Fund and by the Government (for citizens without health insurance). The Hungarian health care system has three political and administrative levels: National, County, and Municipal. The Ministry of Health is responsible for health policy, for the national health care institutions, and for the National Ambulance Service. The county chief physician and municipality chief physician are responsible for administration of the health care management in their respective domains. All of the health care institutions are divided into three levels according to the services they provide: tertiary, secondary, or primary. Primary care is provided by family physicians, pediatricians, and dentists; secondary care is provided in hospitals and outpatients clinics; and tertiary care is provided at national hospitals and university clinics by specialists. Emergency medical services (EMS) in Hungary are divided into two parts: prehospital care and in-hospital treatment. Prehospital treatment and transportation is delivered by the ambulance services, and the emergency intramural care by different levels of EDs in the hospitals. They are categorized according to the pro-
vided care, into ED1 (Emergency Center) and ED2 (Emergency Department) (11).
PREHOSPITAL EMERGENCY CARE IN HUNGARY Access to EMS Patients who become seriously ill or injured in the community usually will be treated and conveyed to hospital by one of the units of the National Ambulance Service. In an emergency, ambulances are accessed by dialing the common national access number 104 (or 112 for a general emergency call). When the incident location has been established, ambulance services are mobilized and further clinical information is relayed by TETRA (Terrestrial Trunked Radio) digital technology from dispatch room staff in 19 regional dispatch centers. Ambulance cars are in constant contact with the dispatch centers by TETRA systems and controlled by AVL (Auto Vehicle Location) terminals. TETRA terminals are also used to record routine ambulance service activity (e.g., velocity of ambulance cars, status of arrival and departure, usage of blue lights), thus freeing up radio time for transmission of other essential information (e.g., clinical details). The response time is used by the government as an important performance indicator for Hungarian ambulance services. Priority dispatch is used by ambulance services in prioritizing emergency calls. It is suggested that the average ambulance response time should be 15 min for the majority of the population. This standard is met in urban areas, but this is difficult to achieve in rural areas. Patient information is passed to the dispatch center, but usually ambulance teams transfer patients to the nearest hospital with an ED. The priority categories are the following: immediate response; response within 2 h; patient transport in rescue preparedness over 2 h (12).
Prehospital Emergency Care in Hungary
Types of Ambulance Units and Training of Personnel In Hungary, one of the main goals of the National Ambulance Service since its beginning has always been to keep the ambulance cars, equipment, and the educational background of the crew unified. To reach this goal, all functions and regulations are centralized, establishing in Hungary a unique ambulance service model. The FrancoGerman model had a great impact on its development. The educational background of the personnel on the ambulances is provided by different types of education. EMTs are trained in health care vocational schools in many cities within the country. Degree programs are offered for ambulance officers at three faculties of health sciences at universities, and medical programs are run by four medical universities with a later possibility of specialization in Emergency Medicine (13). The same protocols are used by the ambulance services all over the country, and are based on the latest developments in the medical sciences.
Ground Rescue Currently, ground rescue is based at 229 ambulance stations throughout Hungary. There are three main levels of ambulance units and other auxiliary vehicles (e.g., motor bike, Mobile Intensive Care Unit, Neonatal Emergency Physician Unit, Mass Casualty Incidents Unit). The basic units are staffed by an EMT (in Hungary called ambulance nurse) and a car driver. The cars are equipped with the most important devices for Basic Life Support (bandages, splints, vacuum mattress, rigid collar [Stifneck®; Laerdal Medical, Wappingers Falls, NY], oxygen cylinder, ventilation bag, suctioning device, oropharyngeal tubes, means of intravenous [i.v.] access, medications for oral use and inhalation). The majority of the cars are also equipped with an Automatic External Defibrillator. EMTs are trained in a 2-year course in one of the institutions for health care vocational education. The entry requirement for the diploma course is a General Certificate of Secondary Education (GCSE) and a minimum of 18 years of age. The core content of this course is developed and approved centrally by the Ministry of Health. Half of the training is hospital and emergency services based. The diploma must be registered by the Ministry of Health. The immediate care skills that can be performed by an EMT are the following: basic resuscitation procedures (basic life support, oxygen administration, oral and nasal airway adjuncts, bag-valve-mask ventilation, laryngeal mask airway, semiautomatic and manual defibrillation); hemorrhage control and wound care; fracture management; spinal injury care and immo-
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bilization techniques; analgesia with inhaled Entonox; management of respiratory emergencies; basic physiological measurements; preparing transport position and fixation; administration of therapeutic drugs (Table 3); performing 12-lead electrocardiography; and supporting paramedics delivering advanced medical care. Car drivers are given shorter-term in-service training in Basic Life Support interventions. The next more advanced ambulances are Ambulance Officer Units staffed by an ambulance officer, an EMT, and a car driver. The cars are equipped with instruments for Advanced Life Support (ALS) including an electrocardiography monitor, defibrillator, intubation equipment, pulse oximeter, i.v. fluid therapy, gastric lavage supplies, perfuser, baby set, scoop stretcher, and a broad range of drugs. Ambulance officer training comprises 4 years of fulltime or part-time degree studies (BSC) in one of the faculties of Health Sciences of the three Universities that run the medical faculties. The course of study, besides the theoretical lessons, requires almost 50% of the time to be on-site practice in different teaching hospitals and emergency facilities. Ambulance officers gain experience, in addition to the EMT skills, in ALS interventions, trauma care, medical emergencies, triage, disaster management, and other emergency procedures. The entry requirements for the ambulance officers’ program are a GCSE and, in the case of part-time studies, 2 years of serving as an EMT. Basic skills above the EMT level are the following: endotracheal intubation; needle thoracocentesis; needle cricothyrotomy; i.v. cannulation; transthoracic pacemaker; i.v. analgesia; and oral, intramuscular, and i.v. drug administration (Table 3). The most advanced ambulances are the Emergency Physician Cars. These are staffed by emergency physicians in addition to an EMT and a car driver. These cars are equipped with all the important devices and medications needed for prehospital emergency medical care, including respirator and endocavital pacemaker facility. Emergency physicians are trained in the most advanced field interventions, including cardioversion, ventilation, anesthesia, and others. Emergency medical education is 3 years of further study to specialize in Emergency Medicine. This can be gained at one of the four medical universities. All members of the staffs of all levels are required to take part in refresher courses yearly. The rendezvous system exists in some cities, where the physician arrives on the scene in a rapid response car with all necessary equipment, but there are no facilities for patient transport. This system seems to be more flexible in some cases. The above-mentioned auxiliary ground vehicles are available in only some regions of Hungary, depending on the needs of the area.
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Table 3. Medication Usage by Ambulance Staff in Hungary in 2008 Medication Usage by Emergency Personnel in Hungary Personnel Name of the Drug
Emergency Medical Technician
Ambulance Officer
Emergency Physician
Tbl Tensiomin Pulv Carbo Medicinalis Tbl Aspirin Tbl Plavix Pulv Natrium hydrocarbonicum
X X X — X
X X X X X
X X X X X
Nitrolingual aerosol Berotec aerosol Sol. Berodual Ventolin Evohaler
X X X X
X X X X
X X X X
Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj Inj
Algopyrin Diclofenac Fentanyl Morphinum-HCL Calypsol Lidocaine 1% Etomidat-Lipuro Propofol 1% Adenocor Betaloc Cordarone Magnesium Sulphuricum Verapamil Epanutin Anexate Naloxone Ebrantil Fenistil Suprastin Cerucal Haloperidol Theospirex Metilprednisolon Solu-medrol Furosemide Nitro-Pohl Midazolam Torex Seduxen Dobutamine Dopamine Tonogen Atropinum sulph. No-spa Heparibene Na Metalyse Oxytocin Glucagen
X — — — — — — — — — — — — — — — — — — — — — — — — — — — — — X X X — — — X
X X X X X X — — X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Inj Inj Inj Inj
Calcimusc Kalium Chloratum Na-hydrogencarbonat Sodium Chloride 0,9%
— — — X
X X X
X X X X
Supp. Nurofen Supp. Rectodelt Sol. Diazepam desitin
X X X
X X X
X X X
Glucosum 20% Hyperhaes 6% Isodex
X — —
X X X
X X X
Main Indication of Drug Per os medication Antihypertensives Absorbents Platelet aggregation inhibitor Laxatives Sublingual or buccal medication Glyceryl TriNitrate Sympathomimetics i.m., i.v. Medications Analgesics
Anesthetics
Antidysrhythmics
Anticonvulsive Antidotum Antihypertensives Antihistamines Antiemetics Antipsychotics Broncho-spasmolitics Corticosteroids Diuretics Nitroglycerin Sedatives Sympathomimetics Parasympatholytics Spasmolytics Thrombolytics Uterotonicum Glucagon Others
Rectal Analgesics Corticosteroids Sedatives Infusions
Prehospital Emergency Care in Hungary
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Table 3. (Continued) Medication Usage by Emergency Personnel in Hungary Personnel Main Indication of Drug
Gases Oxygen Entonox
Emergency Medical Technician
Ambulance Officer
Emergency Physician
Ringer fundin Ringer’s lactate Voluven 6%
X X —
X X X
X X X
Oxygen Nitralgin
X X
X X
X X
Name of the Drug
Inj ⫽ injection; Pulv ⫽ pulvis; Sol ⫽ solution; Supp ⫽ suppository; Tbl ⫽ tablet.
The brands of ambulance cars used are the following: EMT unit, Toyota Hiace and Ford Transit 2.0 TDC 300; Ambulance Officer Unit, Mercedes Sprinter; and Emergency Physician, Mercedes Sprinter.
Air Rescue Ground rescue is augmented by air ambulances. Helicopter rescue is restricted to high-priority rescue in the country. There are seven regions in Hungary (districts of Balatonfüred, Budapest, Debrecen, Miskolc, Pécs, Sármellék, and Szentes) that have an air ambulance rescue system. In case of need they also provide inter-hospital transports. Ambulance flights are restricted to daytime hours. For long-distance transportation (repatriation), there is also an ambulance plane facility available. All air ambulances are equipped with the devices of a Mobile Intensive Care Unit, but an additional Propaq monitoring system is also available onboard. Water rescue and other special rescue, for example, mountain rescue and cave rescue, are provided by different non-governmental organizations. The Hungarian National Ambulance Service is still the most powerful organization, with 5774 personnel providing prehospital emergency care in Hungary (Table 4). In recent years, continuous quality improvement has been introduced in the service to standardize all the procedures related to prehospital emergency medical care.
FUTURE DIRECTIONS IN EMERGENCY CARE IN HUNGARY The Hungarian prehospital emergency medical care service plays an essential role in Hungarian emergency care. The standardized protocols used by the Hungarian National Ambulance Services personnel are identical to the
guidelines developed by international professional bodies. To further ensure consistency and quality in the EMS system and to narrow the gap between prehospital and intramural patient care, the staff is involved in continuous medical education. Based on its organizational origins, a “stay and play” philosophy still characterizes prehospital care in Hungary and no doubt will continue. An Emergency Medical System is rapidly evolving in Hungary at a time of rapid change. The current Hungarian EMS system is highly efficient and provides sophisticated prehospital treatment to acutely ill patients and trauma victims. However, recent developments challenge the system. There is strong evidence that early specific treatment at the scene improves the victim’s outcome. However, this requires a highly qualified, unified professional team. Unfavorable working conditions have caused minor recruitment problems. Also, the number of hospitals in Hungary is being reduced, and patient transport and prehospital medical emergency care are being separated as a result of the Government’s initiative to cut health care costs. The combined effect is that the number of ambulance cars at times may not be adequate, and emergency transport time may be increased. Histor-
Table 4. Distribution of Ambulance Staff by Role, at the National Ambulance Service in Hungary 2000 –2007 Type of Personnel Year
Emergency Physician
Ambulance Officer
EMT
Car Driver
2000 2001 2002 2003 2004 2005 2006 2007
151 177 180 172 190 136 135 125
342 339 374 413 519 491 462 519
2862 2972 3062 3131 3256 2980 2620 2738
2392 2493 2522 2600 2614 2572 2431 2392
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ically, the bulk of this care has been delivered by the state, and this is likely to continue to be the case for the foreseeable future. The development of regional hospitals with resources to manage complex illnesses and injuries throughout Hungary could significantly enhance the standards of prehospital emergency care delivered by the National Ambulance Service. Timely patient access to such centers is likely to remain a significant challenge. Further investment and development in prehospital emergency care networks could improve patient access to emergency care. REFERENCES 1. Felkai T. The establishment of rescue on the rails (A vasúti mentés kialakulása) [Hungarian]. Health at Railways (Vasútegészségügy) 1974;2-3:123. 2. Papp Z. The prominence of the Hungarian rescue (A magyar menetésügy kiemelkedö személyiségei) [Hungarian]. Journal of the Hungarian Society of Emergency Medicine (Magyar Mentesügy) 2001;21:62– 4. 3. Debrodi G. Rescue on the rails (1882–1931) [Hungarian]. Orvostort Kozl 2006;51:147– 64.
4. Felkai T. The history of the Hungarian rescue, book of anniversary (Magyar Mentéstörténet, Jubileumi Emlékkönyv) [Hungarian]. Budapest, Hungary; 1987:27– 45. 5. Maklary L. The ambulance hospital (Mentokorhaz) [Hungarian]. Journal of the Hungarian Society of Emergency Medicine (Magyar Mentésügy) 2004;24:150 – 61. 6. Hungary in Figures 2007. Budapest: Hungarian Statistical Office; 2008. 7. Hungarian Statistical Yearbook. Budapest: Hungarian Statistical Office; 2007. 8. Langhelle A, Lossius HM, Silfvast T, et al. International EMS systems: the Nordic countries. Resuscitation 2004;61:9 –21. 9. Black JMJ, Davies DG. International EMS systems: United Kingdom. Resuscitation 2005;64:21–9. 10. Roessler M, Zuzan O. EMS system in Germany. Resuscitation 2006;68:45–9. 11. Ministry of Health, Social Welfare and Family. Decree No. 60/ 2003. (X. 20). On the minimum standards of providing health care services [Hungarian]. (ESzCsM rendelet az egészségügyi szolgáltatások nyújtásához szükséges szakmai minimumfeltételekröl). Budapest, Hungary: Ministry of Health; 2003. 12. Ministry of Health. Decree NO. 5/2006 (II. 7). On medical rescue [Hungarian]. (EüM rendelet a mentésröl). Budapest, Hungary: Ministry of Health; 2006. 13. Betlehem J, Kukla A, Deutsch K, Marton-Simora J, Nagy G. The changing face of European healthcare education: the Hungarian experience. Nurse Educ Today 2009;29:240 –5.