Elsevier

Resuscitation

Volume 81, Issue 4, April 2010, Pages 427-433
Resuscitation

Scandinavian pre-hospital physician-manned Emergency Medical Services—Same concept across borders?

https://doi.org/10.1016/j.resuscitation.2009.12.019Get rights and content

Abstract

Background

In Scandinavia, scattered populations and challenging geographical and climatic conditions necessitate highly advanced medical treatment by qualified pre-hospital services. Just like every other part of the health care system, the specialized pre-hospital EMS should aim to optimize its resource use, and critically review as well as continuously assess the quality of its practices. This study aims to provide a comprehensive profile of the pre-hospital, physician-manned EMS in the Scandinavian countries.

Methods

The study was designed as a web-based cross-sectional survey. All specialized pre-hospital, physician-manned services in Scandinavia were invited, and data concerning organization, qualification and medical activity in 2007 were mapped.

Results

Of the 41 invited services, 37 responded, which corresponds to a response rate of 90% (Finland 86%, Sweden 83%, Denmark 92%, Norway 94%). Organization and education are basically identical. All services provide advanced life support and have short response intervals. Services take care of a variety of patient groups, and skills are needed not only in procedures, but also in diagnostics, logistics, intensive care, and mass-casualty management. Consistent and detailed medical documentation was often lacking, however.

Differences are mainly related to time variables, patient volume, and service area. The Danish and Swedish services have higher volumes of patient care encounters while the Finnish and Norwegian ones provide a wider variety of medical services.

Conclusions

This survey documented several significant similarities among pre-hospital physician-staffed EMS systems in Scandinavia. Although medical data registration is currently under-developed, Scandinavian physician-manned EMS is a feasible arena for future multi-centre research.

Introduction

In Scandinavia, scattered populations and challenging geographical and climatic conditions necessitate highly advanced medical treatment by qualified pre-hospital services. Pre-hospital, physician-manned Emergency Medical Service (EMS) is an acknowledged and integrated supplement to the basic Scandinavian EMS.1 These specialised services are mainly dispatched by a dispatch centre coordinating all EMS resources using predefined criteria. The extent of the medical benefits of this expensive tool is still a subject of debate.2, 3, 4, 5, 6 Reliable answers to questions about cost-benefit are difficult to find, however, mainly due to methodological problems, as is often the case with emergency medical care. Randomized controlled trials (RCTs) may not be feasible because of ethical and informed-consent issues; a large-scale RCT looking at physician versus non-physician EMS would be very challenging to perform. We are therefore left with quasi-randomized studies, before-and-after studies, and studies on field interventions. The validity of such studies, however well designed, may be limited to the geographical and structural area under investigation. For example, it is not reasonable to infer from studies on pre-hospital airway management by emergency physicians or paramedics to services staffed by anaesthesiologists. In addition, pre-hospital physicians may have different roles in their healthcare systems, and any outcome analysis should take this into consideration. For example, the air ambulance in London (London HEMS) almost exclusively responds to traumas, whereas the anaesthesiologist-staffed search-and-rescue services in Norway cover a much wider range of missions. Sometimes these are carried out under very challenging operating conditions: offshore evacuation of medical and trauma patients, neonatal inter-hospital transfers, rescue operations in the mountains, and transport of intensive-care patients.7 In Denmark, physicians in the urban services frequently make home visits to chronically ill patients and initiate treatment on-scene, thus averting hospital admission.8 The on-call physicians in the pre-hospital service in Helsinki interpret electrocardiograms transmitted from the ambulance service and make decisions about the need for on-scene thrombolysis or rapid transfer to percutaneous coronary intervention.

Just like every other part of the health care system, the specialized pre-hospital EMS should aim to optimize its resource use, and critically review as well as continuously assess the quality of its established practices. Adequate monitoring will not only ensure up-to-date medical practices, but could also provide a management tool for decision makers.9, 10 To facilitate public health monitoring, the European Union Emergency Data (EED) project established common indicators to compare EMS systems11 and recommended five key variables to be included in European Community Health Indicators (ECHI). These five indicators are: Unit (i.e. Service) Hours per 100,000 inhabitants per year, response time, rate of highest priority missions per 100,000 inhabitants per year, rate of “First Hour Quintet” diagnoses (cardiac arrest, severe trauma, severe respiratory distress, chest pain and stroke) per 100,000 inhabitants per year, and rate of ALS interventions per 100,000 inhabitants per year. While these key indicators may serve as a useful starting point, there is currently no common data-monitoring system for the specialized physician-manned services in Scandinavia, which makes cooperative research difficult. More importantly, we do not even know if the concept of physician-staffed pre-hospital services is the same across all the Scandinavian countries.

The “ScanDoc” network, consisting of EMS professionals across Scandinavia, was established to develop definitions and a common core data set. This study aims to provide a comprehensive profile of the pre-hospital, physician-manned EMS in the Scandinavian countries. In this study, we ask: “Does the pre-hospital EMS staffed with a specially trained physician in Scandinavia have similar characteristics across borders?”

Section snippets

Methods

The study was designed as a web-based cross-sectional survey. It was initiated in July 2008 and closed in May 2009. In addition to questions developed earlier for comparisons of EMS systems in the European Union and the five EED project key indicators,11 we developed new survey questions considered to be useful for overall comparison.

The survey was divided into three main sections: structure, qualification and medical activity (Appendix C). The Structure section contained questions on

Results

Of the 41 invited services, 37 responded, which corresponds to an overall response rate of 90% (Finland 6/7, 86%; Sweden 5/6, 83%; Denmark 11/12, 92%; Norway 15/16, 94%) (Fig. 1). One Swedish service answered only a few questions. The four non-respondents were 2 ground-based services and 2 helicopter-based services. All these were publicly funded, anaesthesiologist-staffed units and integrated in the EMS system similar to the responding services. Results from these services are not expected to

Discussion

Despite obvious differences between pre-hospital physician-staffed EMS systems in Scandinavia, our study revealed several significant structural and operational similarities. System indicators on a macro-level, such as public versus private health care, socioeconomic profile, and population health, are all important for country comparisons. In Scandinavia, these are quite similar. This study documents that all services provide advanced life support and have short response intervals.

Conclusions

This survey documented significant system similarities among pre-hospital physician-staffed EMS systems in Scandinavia. Differences were mainly seen in time variables, patient volume, and service area. The Danish and Swedish services have higher volumes of patient care encounters while the Finnish and Norwegian ones provide a wider variety of medical services. Although medical data registration is currently under-developed, Scandinavian physician-manned EMS is a feasible arena for future

Conflicts of interest statement

The principal investigator (AJK) is funded by the Norwegian Air Ambulance Foundation which is the mother company of the largest air ambulance contractor in Norway. HML is director of research in the same company. MC, ES and JK have no competing interests.

Acknowledgements

We thank the Unit for applied clinical research, NTNU, Norway, especially Berit Bjelkåsen and Elena Ivanova, for excellent support on questionnaire construction, maintenance and server space during the study. We also thank Dr. Erika Christensen and Dr. Mikkel Andersen for their assistance in data collection in Denmark and all services responding to the survey.

References (16)

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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.12.019.

1

Norwegian Air Ambulance, P.O. Box 94, N-1441 Drøbak, Norway.

2

See Appendix A.

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