Deficits in Emergency Care - Are Good Concepts Poorly Realized?

[Emergency care for traffic accidents in Bavaria: current process analysis depending on hospital and emergency service structures]

A change is emerging in the hospital landscape due to health political measures, which in consequence also influences the prehospital medical care in emergencies. The main focus of this study was to gather information about emergency medical care after traffic accidents on the basis of data from Bavarian emergency medical services. In 2006 there were 14,261 traffic accidents in Bavaria where an emergency doctor attended the scene. The patients were primarily cared for by land-based rescue services and air rescue services were only used in 19.1% of the cases. Of the patients involved in a traffic accident 47.6% were transported to a primary health care hospital. A prehospital interval of more than 60 min occurred in 20% of the missions. Of the patients 96.2% were transported to tertiary or maximum care hospital by air rescue services but emergency facilities were, however restricted to daylight hours. There was a further limitation due to the routine duty hours in hospitals as only 36.7% of accidents occurred during this time intervall. An increase of admission post trauma in maximum care clinics occurred from 2002 until 2006 while simultaneously the prehospital period was extended. In order to assure sufficient trauma care for seriously injured persons a continuous 24 h availability of emergency trauma facilities is necessary. For this purpose it is necessary to establish regional trauma networks between receiving hospitals as well as air rescue services at night time. Furthermore, a cost-efficient compensation of the structural, personnel and logistic expenses for the treatment of the severely injured has to be assured.

Realistic assessment of the physican-staffed emergency services in Germany

In Germany the emergency medical services, which include dispatching emergency physicians to the scene, are considered to be among the best in the world. However, the hospitals admitting these patients still report shortcomings in prehospital care. The quality of an emergency medical service depends on both formal qualification and experience in managing such emergencies. Therefore, we determined how frequently emergency medical service physicians in Germany actually encountered complex and demanding emergency situations outside the hospital and how often they had to carry out emergency interventions. We therefore evaluated data from more than 82,000 ground emergency medical service scene calls registered in the MIND ("minimaler Notarztdatensatz") data base of the state of Baden-Wuerttemberg, Germany and more than 47,000 helicopter emergency medical service scene calls from the "Luftrettungs-, Informations- und Kommunikationssystem" (LIKS) data base of the German ADAC air rescue service. The results, which were unexpectedly distinct, impressively demonstrate that in part emergency medical service staff only encountered some emergencies very rarely. In particular, patients with life-threatening conditions such as acute coronary syndrome, stroke, head trauma, as well as multiple trauma were only treated once every 0.4-14.5 months and cardiopulmonary resuscitation and intubation were only carried out once every 0.5-1.5 months. Furthermore, a time period of 6 months to more than 6 years may pass before a chest tube has to be placed. There are, of course, considerable differences between ground and helicopter emergency medical services. Particularly in areas where the frequency of such emergency cases is low, the clinical experience required to competently manage a demanding emergency situation cannot be gained or maintained just by working in the emergency medical system. As a result of the general pressure to cut costs and also of changes in hospital politics, however, only highly qualified and experienced emergency medical services may survive in Germany in the long term. In addition to formal qualifications and accompanying practice-related courses, future emergency medical service personnel should be drafted from clinical department staff that are experienced in treating severely ill and severely injured patients.