1. Status of Emergency Medicine Around the World EMERGENCY MEDICINE IN GERMANY PROF.DR.W.F.DICK

2. OVERVIEW Descriptive information/statistics –Country information –EM-Specialty status –EM system information Challenges/innovative strategies Summary

4. COUNTRY INFORMATION 1 Federal Republic of Germany Inhabitants:83 Mio (2001): 231 / Sqkm Age: 0-14 y -12.6 Mio :15- 65y - 55.7 Mio: > 65 y -14.0 Mio Climate:Moderate Finance:Compulsory Insurance GNP/Capita:24.650 €

5. COUNTRY INFORMATION 2 „Burden of diseases“ Life expectancy (years) : 81 F - 75 M Major causes of mortality: 828.541 total –Cardiovascular 30 % –Malignancy10 % –Endocrine diseases: 3 % –Respiratory diseases 6 % –Trauma/Intoxications etc. 4 % –Various others48 %

6. COUNTRY INFORMATION 3 Health Care System Health Care System :Nat./Reg./Pub./Priv. Insurance compulsory:Public/Private Hospitals(except milit.):2.240 of different categories University Hospitals:40 * Hospital beds (2001):550.000 (80%)

7. COUNTRY INFORMATION 4 MEDICAL EDUCATION Number of Medical Schools: 40 Length of study:6 years PG Training leading to spezialisation 5-6 years Medical Specialty BoardFinal exam certification

8. CONTACT INTERVALS The German EMSS has to guarantee a call-to-patient-contact-interval of: - 10 minutes in 80 % - 15 minutes in 90 % of all cases

9. EM-SPECIALTY STATUS EM is recognized as a supraspecialty to... not as a specialty of its own Recognizing bodies are regional medical councils Officially recognized for 2-10 years Board certification process consists of a training program and a final exam

10. EM-SUPRASPECIALTY STATUS 1 In addition to the curriculum of the base specialty, trainees have to undergo: 30 months hospital practice in emergency care, including 6 months ICU,ED and/or anesthesia under supervision and instruction of a state certified trainer........

11. EM-SUPRASPECIALTY STATUS 2 50 prehospital emergency operations(MLSU, helicopter etc.)under the guidance of an experienced EMPhy. A course program of 80 credit hours on general and special aspects of emergency medicine Final examination at regional medical councils

12. EM-SUPRASPECIALTY STATUS 3 1.Flight physiology2 h 2.Medical equipment4 h 3.Transport media4 h 4.Flight safety 4 h 5.Documentation/TQM2 h 6.Case scenarios2 h

13. EM-SUPRASPECIALTY STATUS 4 Red Cross and comparable organisations are concerned with prehospital EM (anesthesiologists, internists, surgeons pediatricians ) In-hospital emergency care is provided by different specialties

14. EM-SYSTEM INFORMATION 1 Health Care is a responsibility of the Federal Government EM is a resonsibility of State Governments EM is considered as part of the transport system The EMS operates on local level

15. EM-SYSTEM INFORMATION 2 Prehospital emergency care Type of ambulances: Basic ( 2 EMTs) Advanced(1 Param. +1 EMT) MLSU( EMPhys..+ 2 Param.) -EMT : 6 months -Paramedic :2 years -EMPhys. :s.above

16. EM-SYSTEM INFORMATION 3 DISPATCH MECHANISM Bystander to dispatch center public telephone or cellular phone Dispatch center (paramedics + EMTs) to ambulance or MLSU (paramedics) via radio communication

17. EM-SYSTEM INFORMATION 4 FUNDING Funding is provided by health care insurance companies on a fee for service basis EMS-budget : < than 1 % of the total health care budget ( 1.25 Bio. € of 325 Bio.€ / year) Expenses /operation -Regular ambulance : 75 to 200 € -MLSU :400 € -Helicopter : 40 €/Min

18. EM-SYSTEM INFORMATION IN-HOSPITAL EMERGENCY CARE The scope of patient care provided depends on the case and the hospital category : –Basic Care –Intermediate Care –Maximum Care –„Supramaximum Care“

19. EM-SYSTEM INFORMATION IN-HOSPITAL EMERGENCY CARE 2 Intermediate and some maximum care hospitals provide emergency care in one central ED; other maximum and all supramaximum care hospitals provide EM in 2-3 separate „receiving areas “(surgical,internal,pediatric ) Accordingly,the multispecialty approach is common, but based upon close cooperation with other hospital departments

20. CHALLENGES AND STRATEGIES TOP CHALLENGES 1.EM is part of the public transport system 2.There is no general emergency phone number 3.Bystander preparedness is limited 4.Paramedic training program is under revision 5.Status and number of EMS-Medical Directors is insufficient

21. CHALLENGES AND STRATEGIES I TOP CHALLENGES 1.Legislation requires EMS to be a component of the public transport system; i.e.the system is underfinanced due to the reimbursement system rather than by on scene patient care

22. CHALLENGES AND STRATEGIES 1 TOP CHALLENGES 2.There is no general public emergency phone number An emergency patient can either call 112 via cellular phone or 110 (Police) 112(fire fighters), 19222 (EMS dispatch center)or 19292(office based physicians)

23. CHALLENGES AND STRATEGIES I TOP CHALLENGES: 3.Bystander preparedness is limited According to study figures,only between 10 and 30 % of bystanders are prepared or willing to carry out first aid measures. Ministeries and school administrations are rarely helpful in improving the situation

24. CHALLENGES AND STRATEGIES I TOP CHALLENGES: 4. Paramedic training programs are under revision : The present 2- year training program is under revision with respect to the status of paramedics,their skills and capabilities

25. CHALLENGES AND STRATEGIES I TOP CHALLENGES 5.Installation of EMS-Medical Directors is insufficient Among the various EMS-organisations,regional Red Cross branches entirely oppose the installation of the position of a medical EMS director responsible for all organisations

26. CHALLENGES AND STRATEGIES II Mechanisms by which strategies are developed and implemented are: -Discussion and development in GMC-councils, critical care organisations etc. -Presentation to the „Standing Conference of EM“ -Presentation to the political committees and organisations -Public hearings etc.

27. SUMMARY 1 MAJOR POINTS Country information Specialty and supraspecialty status situation System information Dispatch mechanism information Funding mechanism information In-hospital emergency care situation Challenges and strategies

28. SUMMARY 2 CONCLUSIONS + All patients are financially covered(Insurances) + The system works fairly well ; however -Structure and funding need to be improved -Prehospital - and immediate in-hospital care have to be integrated - One common emergency number ist needed - Status of Medical Directors has to be improved

29. T H A N K Y O U A n y Q U E S T I O N S ?