Starting an EM Residency in Europe Anna Maria Ferrari M.D. President of the Italian Society of Emergency Medicine (www.simeu.it)

EMERGENCY MEDICINE IN ITALY The foundations of emergency medicine were first seen in 1969 with laws 128, 129, and 130, which outlined a need to provide medicine care in the acute setting. However, it was not until 1977 that the first emergency department was established in Turin Health care reform legislation in 1992 allocated additional funds for the development of emergency care systems, including the institution of 24-hour dispatch centers and a common toll-free access number 118 analogous to 911 in America

EMERGENCY MEDICINE IN ITALY Additionally, the roles of the ED and the EMS system were more clearly defined. A larger division, called the “Department of Emergency Admittance” (DEA), was created. The DEA deals with all aspects of emergency care delivery, and includes the ED, the dispatch center and often, a short-term observation area. The 1992 legislation was a major step in the advancement of emergency medicine in Italy, and effectively has created a separate hospital division of acute care medicine.

EMERGENCY MEDICAL SERVICES Medical care in Italian EDs is usually provided by physicians with specialty training in internal medicine. Other specialists, such as pediatricians, gynecologists, and so on, are available for consultation on either an in-house or on-call basis. Triage is performed by nurses. Generally , physicians are assigned full-time to the ED. However, recognizing the growth and development of emergency medicine as a distinct medicine discipline in the Anglo-American model, the Italian health care system has acknowledged the need for more specialized physician training in this area

EMERGENCY MEDICAL SERVICES The development of prehospital care systems in Italy has paralleled the ED experience. Several regions have developed an advanced out-of- hospital system. These advanced EMS units are usually staffed by a driver and a nurse trained in Advanced Life Support (ALS), and physician if required. In many regions, ambulances are also staffed by volunteers with BLSD training.

Number of EMERGENCY MEDICAL SERVICES The Network of Hospitals in Italy In Italy are present: 742 public Hospitals:  427 Hospitals with First Aid 196 Hospitals with D.E.A. of I level 119 Hospitals with D.E.A. of II level

Dispatch Centers 118 in national area: n. 103 Number of EMERGENCY MEDICAL SERVICES 2005 Dispatch Centers 118 in national area: n. 103 Calls to 118: n: 13.841.182 Visits in Emergency Department: 28 million Patients admitted in Hospital: 17,9%

SIMEU Italian Society of Emergency Medicine Since 2000 SIMEU collects all the scientific Italian emergency Societies

1996 Federation :FIMUPS 2000 SIMEU STATUTE ANMU SIMPS Federation :FIMUPS 2000 SIMEU STATUTE ......” to promote and encourage the establishment of the Specialty in Emergency Medicine, “ Obiettivo statutario

EMERGENCY MEDICINE EDUCATION In 1992 the need for more specialized training in emergency care was recognized and a branch of internal medicine was dedicated to emergency medicine Until two years ago, physicians with an interest in emergency medicine completed the first 3 years of internal medicine training, followed by emergency medicine for the last 2 years, with special training in trauma and orthopedic management and stabilization. In the last ten years the concept of dedicated emergency medicine specialty schools (ie, residency training) has been developed.

EMERGENCY MEDICINE EDUCATION In November 1996, simultaneous with the implementation of European Community standards for specialty school training, guidelines for emergency medicine specialty training were also defined. These guidelines attempted to define more explicitly the curricular needs of emergency medical specialty education. However, they also indirectly served to define the scope of emergency medicine practice in Italy.

Academic Year 2008/2009: the Specialty of Emergency Medicine starts EMERGENCY MEDICINE EDUCATION DPR 10.12.1997: establishment of the role of Emergency Physician Decreto Ministero Università 17.02.2006: establishment of New Specialty of Emergency Medicine. Academic Year 2008/2009: the Specialty of Emergency Medicine starts

The 25 Universities that have started the school: Bari, Brescia, Cattolica del Sacro Cuore, Firenze, Genova, L’Aquila, Milano-Bicocca, Modena e Reggio Emilia, Napoli “Federico II”, Padova, Parma, Pavia, Perugia, Piemonte Orientale, Pisa, Roma “La Sapienza” I e II Facoltà, S. Raffaele Milano, Sassari, Siena, Seconda Università Napoli, Torino, Trieste, Udine, Verona

STANDARD and REQUISITIONS for ACCREDITATION of SCHOOL G. U STANDARD and REQUISITIONS for ACCREDITATION of SCHOOL G.U. 48 del 26 Febbraio 2008 Decreto 22 gennaio 2008

EMERGENCY MEDICINE Fundamental standard structures STANDARD STRUTTURALI Livelli minimi di accettabilità Struttura di sede Struttura collegata FONDAMENTALI PER LE STRUTTURE   Devono essere tutti presenti sia nella struttura di sede che in quella collegata Pronto Soccorso comprensivo di: Zona triage Sala rossa Sale di visita SI Osservazione Breve o Letti Tecnici Degenza (Medicina di Urgenza) Sistema 118* *Struttura indispensabile nella rete formativa

MEDICINA DI EMERGENZA-URGENZA Standard strutturali generali e diagnostici Livelli minimi di accettabilità Struttura di sede Struttura collegata C) SERVIZI GENERALI E DIAGNOSTICI DELLA AZIENDA OSPEDALIERA CHE OSPITA LA STRUTTURA DI SEDE E LA STRUTTURA COLLEGATA. Questi Standard non sono richiesti per la struttura collegata Sistema 118 Diagnostica per immagini SI Ecografia Medicina di laboratorio Servizio di Anestesiologia

MEDICINA DI EMERGENZA-URGENZA Standard assistenziali Livelli minimi di accettabilità Struttura di sede Struttura collegata ACCESSI OSPEDALIERI e RICOVERI ANNUALI Accessi in PS 35.000 20.000 Ricoveri di pazienti attraverso il PS 7.000 4.000 INTERVENTI TERRITORIALI Eventi 15.000

Main STRUCTURE The structures within the School of Specialization are the university management structures, suitable and equipped for the organization and implementation of vocational training activities in specialized medical and organizational management, administrative, educational and medical technology related activities and the coordination and / or direction of the same;

Related structures The second goal of accreditation is to have related structures that support the main structure in the training of the specialists

Complementary structures Should the school need to use specialized services, activities, workshops or other material that may not be present in the main structure or related structures, the School enters into agreements with complementary structures

The Specialist in Emergency Medicine The Specialist in Emergency Medicine must have completed their theoretical knowledge, scientific and professional fields of the first diagnostic analysis (both intra and outpatient) and the initial treatment of urgent medical, surgical and trauma, so the specialist in Emergency Medicine must have acquired the professional skills and scientific knowledge in the field of physiopathology, clinic and treatment of medical emergencies. So they can operate independently in compliance with ethical principles

Ministerial Decree 1 agosto 2005 G. U. 5 novembre 2005 n Ministerial Decree 1 agosto 2005  G.U. 5 novembre 2005 n.285 - Supplemento Ordinario n.176 Riassetto Scuole di Specializzazione di Area Sanitaria At least 70% of all the training activities shall be devoted to the performance of vocational training activities (practices and training), equivalent to 210 CFU for the types of schools divided into 5-year course

mandatory vocational experience have participated for at least 3 years, medical activity - including watches daytime, night and holiday - in the body for emergency-Acceptance - and related structures - identified in the regional training network  have drafted and signed at least 300 medical records of patients of the Emergency-Acceptance structures  having spent at least 3 weeks per year for at least 3 years in shifts of territorial emergency

Faculty University professors: professors and researchers Non-university teachers that work in related structures, with at least 10 years of experiences (max 30% of the teachers, taking a contract) Lecturers: experts of emergency (number max of 10% of teachers), only in the absence of university Presence of a tutor (maximum 3 student per tutor) REQUISITI GENERALI E SPECIFICI DI IDONEITÀ DELLA RETE FORMATIVA all2 al DM 29 marzo 2006

Manifesto of Emergency Medicine RESPONSIBILITIES OF EMERGENCY PHYSICIAN The areas of expertise in Emergency Medicine : • Patient Care • Medical knowledge and clinical skills • Communication, collaboration and interpersonal skills • Professionalism, ethics and legal and organizational skills • Service management • Education and Research..

Core Curriculum Cardiovascular Emergency 1. Develop the skills required to stabilize the patient in cardiogenic shock, pulmonary edema and severe arrhythmias. 2. Develop the skills necessary to manage a patient intubated and to perform the procedures required for hemodynamic monitoring. 3. Develop the ability to assess and treat patients with acute myocardial infarction and be able to assess the most suitable treatment (thrombolysis, percutaneous angioplasty, surgical revascularization). 4. Developing skills in interpreting ECG and echocardiogram. 5. Develop the ability to assess and treat patients with loss of consciousness and be able to assess the most suitable treatment. 6. Develop the ability to assess and treat patients with pacemakers and able to assess the most suitable treatment. 7. Show that it can make appropriate use of consultants for the proper management of patients with heart problems.

Core Curriculum Cardiovascular Emergency 8. Demonstrate the skills necessary to perform the following procedures and interpret the relevant data derived from the same a Central venous catheterization b Right heart catheterization with Swan-Ganz catheter c Placement of cardiac pacemakers by venous or external d Placement of arterial line e Oro-tracheal intubation f Thoracotomy with needle g Bladder catheterization with Foley h. Thoracentesis i. Pericardiocentesis j. Management of mechanical ventilation k. Cardio-pulmonary resuscitation 9. Become familiar with the execution and interpretation of vascularultrasound

These are the areas included in the competence of the core curriculum Cardiovascular Emergencies Dermatological Emergencies Endocrine and Metabolic Emergencies Emergencies ENT and dental emergencies Gynecological and Obstetric Emergencies Gastrointestinal Emergencies Hematologic and Oncologic Emergencies Infectious and Immunological Diseases Sepsis Musculoskeletal Emergencies Ophthalmic Emergencies Pulmonary Emergencies Neurological Emergencies psychiatric disorders and behavioral Anesthetic Emergencies Renal and Urological Emergencies Emergency Medicine Pediatric Surgical Emergencies Emergency- Emergency Diagnostic Imaging Intensive Care Pediatric Intensive Care Toxicological Emergencies These are the areas included in the competence of the core curriculum

Thank you for your attention