Future of Emergency Medicine: the situation in France Dr Eric Revue Emergency Physician Toxicologist Chief of the Emergency Department and Prehospital EMS Hospital Le Coudray – Chartres (France) Secretary of the International Committee of the French Society of Emergency Medicine (SFMU) Chair of the Website of the European Society of Emergency Medicine (EuSEM) ericrevue@yahoo.fr Hi everyone, I am Eric Revue from France . I am very glad to be with you and I would like to thank Jessie for this very kind invitation to this conference in Washington. I would like to say hello to my colleagues from United States , Canada, Denmark and Singapore and the audience in Washington DC. Let me present some data of the Health care system in France and particularly what works in our Emergency System George Washington University Washington DC (USA)

Here are some data to compare France and United Sates Here are some data to compare France and United Sates. The main difference is the ratio between public and private hospital. French public hospital treat all emergencies in two different categories of ED “non vital emergencies” and “vital emergencies” with a few real trauma center (for instance there are 4 Trauma center in Paris) the mean number of patients in French ED is 25000 patients every year

The French Health Care system French citizens have universal health insurance coverage > 3000 Emergency Physicians Organization for Economic Cooperation and Development (OECD) France = N° 1 Health System in the world (WHO) A recent report by the Organization for Economic Cooperation and Development (OECD), indicates that France ranks is well above the OECD average on a range of key indicators of health system. French citizens have universal health insurance coverage and are free to navigate and be reimbursed for care in a system that includes solo-based, fee-for service private practice for ambulatory care and public hospitals for acute institutional care. The health insurance system grants people access to the registered health care professional of their choice. There are no gatekeepers regulating access to specialists and hospitals. By French law the ED cannot deny care to patients on the basis of chief symptoms and vital signs.

Data: WHO Europe = 738 681 069 The number of Emergency Physicians (EP) in Europe varies hugely. On this slide you ‘ll see a comparison of number of physicians. In a recent report from the European observatory of health system, demography of medical profession is critical, particularly in Emergency Medicine EuSEM: 15000 affiliates members The French Society of EM (SFMU) with > 3000 members is marking efforts to establish and support the development. European medical specialties are represented in Brussels by the Union Europeenne des Medecins Specialistes (UEMS), a non-governmental organization promoting free movement of doctors within the European Union. EM is a relatively young specialty in France (2004). As is most European countries, EM is at the early stage of development, with a4 year training program.

Number of ED visits in France/ year (reference = 100 in 1996) France ED in 2011 Pop: 65 Millions inhabitants (2,2 M Paris, 11,5 M Ile de France) 630 Emergency Departments in France (96 Paris Ile de France) 14 Millions visits (+4 % / year) > 1 Million pediatrics > 3 Millions (+ 6,3%) in Paris IDF(800 Short Stay Unit beds) + 50 % of ED visits in 10 years (1990- 2000) > 17 % admit hospital 81 % discharge from ED 2 % transfer to another hospital + 3 % emergency call SAMU (112) 1,4 Million in Paris IDF However, health professionals staffing emergency departments of public hospitals in France, complain of deteriorating working conditions due to overcrowding. > 100.000 Intensive care Mobile Unit (SMUR)/year in 2008 (+ 4%) > 300 visits in ED /1000 >100 patients/day (10 % > 75 year old 30 % child) Between 1990 and 2005, there was a 64% increase in ED visits in France. The rising rate of ED admissions to hospital is partly the result of an increasing population with an increasing number of visits. In 2004, a national study of 150 French EDs, young men (< 15 years old) represented 29 % of non urgent visits. Number of ED visits in France/ year (reference = 100 in 1996)

Causes of ED Overcrowding in France Input: overall increase in patient volume Ignorance of GP’use : 4,7 times/year General Practitioners: 285 GP’s /1000 inhab in 2025 Facilities and rapid access to immediate care Nearby hospital, Free –of- charge service ( apparently) Throughput: Patient : need of X ray or quick laboratory tests ? delays +++ Elderly patients (> 80 yo) with chronic diseases visit ED > 50 % admit Perceive a need for hospital bed. shortage of on-call specialty consultant or lack of availability Working Time Directive for ED personnel and the French “35 hours” law (48 h EP) Shortage of nursing staff Output: lack of beds for patients admitted to the hospital Lack of nursing home < 15 beds/1000 hab (> 75 years old) Input:However, when French hospitals are perpetually functioning at greater than 90% of their inpatient capacity, they are ill equipped to handle surges in the number of admissions. Inadequate inpatient capacity for a patient population with increasing severity of illness forces the ED to serve as a holding area for admitted patients. GP: The French consult their doctors more often (average 4,7/year,they can visit several general practitioners), are admitted to the hospital more often, and purchase more prescription drugs. Patients have a free choice of doctor, and do not need a referral from a general practitioner in order to consult a specialist. Doctors benefit from total freedom to choose where they wish to practice, and geographical disparities in the distribution of doctors have existed for a long time. Population of GP in France is still decrease ( < 3 GP/ 1000 patients) with an increasing number of female doctors. Throughput: ED complain about the implementation of the EU Working Time Directive for physicians and the enforcement of the French “35 hours law” for other members of staff increased staff pressure. Lack of sufficient personnel has been cited as one of the causes of the high mortality observed in the particularly hot summer of 2003 or winter epidemics. + 40 % of elderly patients > 80 years old in 2007 in ED (+ 10 % in Paris and Ile de France 2000 – 2004) and > 50 % are admit through the ED. Out Put: The primary determinants of ED overcrowding are not related to patient throughput inside the ED but actually originate outside the ED. Of these, the two most important determinants of ED overcrowding pertaining to the critically ill are an increasing volume of high-acuity patients presenting to the ED and insufficient inpatient capacity.

French Pre-hospital system EMS 100 % of France is manage by a prehospital EMS (SAMU) median response time with of medical Unit (SMUR) EMT is < 20 mn Two major models of emergency care delivery exist in Europe today: the Anglo-American and the Franco-German model. Emergency calls for the Emergency Medical System (“SAMU”) increase every year. A 24/7 dispatch for EMS across France similar to the US 911 (Phone number “15”), is answered by an emergency physician, who in 30% of cases provides only medical advice, but does not send an ambulance for the patient. Physicians treat patients at the scene, during transport, and in the hospital. EMS services cans be reached by dialing “15” everywhere in France. EMS crews have an access to an Emergency Physician via telephone, who are stationed in regional dispatch centers of the Service d’Aide Medicale d’Urgence (SAMU) talking to a direct “hands on” approach to prehospital care. Emergency response to medical calls are conducted by the Service Mobile d’Urgence et Réanimation (SMUR with teams including an emergency physician, an emergency nurse and a nurse aide. To date, however, there are limited multinational studies that directly compare 2 models of emergency care Franco-German vs Anglo American. There are no studies of morbi/mortality to evaluate the paramedics system. 2 models in Europe : Franco-German (60 %) vs Anglo American (30 %) ? There are no studies of morbi/mortality to evaluate the paramedics system. Data are effective in France for the SAMU’s management of the Acute Coronary syndrome

What works in French Emergency Care system ?

Best practices of the Acute care system French Society of Emergency Medicine (2005) Input: Anticipation of delivery of care to patients Protocols ED /Medicine wards Coordination GP /Hospital/ Walk in Center Shortcut : direct entrance through ED Throughput: Bed’s management : nurse or physician “temporary emergencies beds unit” Avoid requisition of beds Multidisciplinary ED with internist Alternatives : hospitalization “at home” Channels for elderly patients Interdisciplinary geriatric palliative care team In 2005, the French Society of Emergency Medicine (SFMU) published different measures to improve and to solve overcrowding in ED. French opinion leaders have reported that ED crowding will not be alleviated until hospitals adopt a multidisciplinary, system wide approach focused on solutions to inpatient capacity constraints. Reduction in admissions is an important aim of ED working policy to overcome the problems of a shortage of inpatient beds, overcrowding, rising costs and exhausted resources. In 2006, the French Society of Emergency Medicine (SFMU) published recommendations to improve and to improve ED crowding. These recommendations are included in Table 1. Carasco V. Activity of French Emergency Departments in 2004: study and results. Etude DRESS N° 524; 2006   Baubeau B, Deville A, Joubert M. Emergency Department visits in France from 1990 to 1998, a growing need for non urgent visits. DRESS N° 72 2000 French Society of Emergency Medicine (SFMU) : Situation of Emergency Departments in France. Available at :http://www.sfmu.org/documents/ressources/referentiels/Aval_SU_SFMU_mai_2005.pdf (French)

Future of EM in France EM specialty in 2004 but more is need… Lack of General Practitioners (mean age > 50 years old)  number of patients in ED  Number of hospitals (Paris ++) emergency physicians more efficient in ED than prehospital EMS (nurses in ambulances ?) Prehospital useful MI ++ , Stroke ? Need to prepare and training for mass casualties , bombing, flu… in ED and prehospital EMS 70 % of French EP want to change job/situation in hospital

Thank you !! Asterix by Uderzo