models of emergency medicine in the world
TRANSCRIPT
Models of Emergency Medicine in the world
Eric Revue MD Head of ED and prehospital EMS Chartres (France)
European Society of Emergency Medicine (EuSEM)
The future of Emergency Medicine
No conflicts of interest except hellip
EMS amp EM amp EMTs amp EPs
bull Definitions ndash EMS (Emergency Medical services) is the
emergency care in the pre- or out-of-hospital setting by bull EMTs = Emergency Medical Technician bull Paramedics = highest level of EMT
ndash Levels vary within and between countries ndash Up to 5 years of training
bull Nurses or doctors
ndash Working on ambulances helicopters HEMS Helicopter Emergency Medical Services (UK HK Germany Canada France Japan Australiahellip)
Myth ldquoEmergency care is expensiverdquo
EM amp EMS
In many countries Emergency Medicine is EMS
ndash Physicians are on ambulances
bull But are these really Eps
ndash And subspecialists are in the ED
bull (eg surgeons pneumonologists etc) see their own patients in a common ED or in separate specialty specific receiving areas
bull They are not really emergency physicians
What is the objective of EMS
1 Life-threatening injuries are appropriately treated promptly to maximize survival
2 Potentially disabling injuries are treated appropriately to minimize functional impairment
3 Minimize Pain and psychological suffering
EMS
Prehospital Care
Emergency Department
Transport
Varies from country to country Should be linked to Health Facilities
When pre-hospital transportation is poor or absent deaths that could have been prevented occur
When quality of care is poor communities may be discouraged from promptly taking patients even when the capacity exists to transport patients
The 2 General Types of EMS Systems
Anglo-American system Franco-German system
ldquoScoop and Runrdquo ldquoStay and Playrdquo
Prehospital care by
paramedics
Prehospital care by
Emergency physicians
Patients delivered to hospital-based
AED staffed by EP
Patients delivered directly
to inpatient services
(ACS Stroke MultiTrauma)
Bring the patient to the doctorrdquo Bring the doctor to the patientrdquo
May just transfer problems
to the nearest hospital
May take more time onndashthe-scene Cost +++
models in Europe Franco-German (60 ) vs Anglo American (30 )
Countries Utilizing the
American-Anglo EMS System Type
bull USA
bull Canada
bull United Kingdom
bull Ireland
bull Australia
bull Hong Kong
bull Mexico
bull South Korea
bull Iran
European Countries Physicians Provide
most Prehospital Care
bull France
bull Germany
bull Austria
bull Russia
bull Ukraine
bull Italy
bull Spain
bull Poland
bull Estonia
bull Croatia
bull Slovenia
bull Switzerland
bull Hungary
bull Czech Republic
bull Slovakia
bull Portugal
bull hellip
Cardiovascular diseases Top Ndeg1 in the world
175 Million people killed by cardiovascular diseases 74 million people died ischaemic heart disease
67 million people died stroke
in 2012
Globalization of need for EMS
Number of Road traffic death rate
China gt 261000 deaths India 207000 Nigeria 35000 US 34000 Russia 27000 Turkey 6687
httpgamapserverwhointghointeractive_chartsroad_safetyroad_traffic_deathsatlashtml
New Terrorist Threat
bull Adequate preparation bull rapid logistical response bull short transport times bull immediate access to OR bull methodical multidisciplinary care bull Military Medicinehellip
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
No conflicts of interest except hellip
EMS amp EM amp EMTs amp EPs
bull Definitions ndash EMS (Emergency Medical services) is the
emergency care in the pre- or out-of-hospital setting by bull EMTs = Emergency Medical Technician bull Paramedics = highest level of EMT
ndash Levels vary within and between countries ndash Up to 5 years of training
bull Nurses or doctors
ndash Working on ambulances helicopters HEMS Helicopter Emergency Medical Services (UK HK Germany Canada France Japan Australiahellip)
Myth ldquoEmergency care is expensiverdquo
EM amp EMS
In many countries Emergency Medicine is EMS
ndash Physicians are on ambulances
bull But are these really Eps
ndash And subspecialists are in the ED
bull (eg surgeons pneumonologists etc) see their own patients in a common ED or in separate specialty specific receiving areas
bull They are not really emergency physicians
What is the objective of EMS
1 Life-threatening injuries are appropriately treated promptly to maximize survival
2 Potentially disabling injuries are treated appropriately to minimize functional impairment
3 Minimize Pain and psychological suffering
EMS
Prehospital Care
Emergency Department
Transport
Varies from country to country Should be linked to Health Facilities
When pre-hospital transportation is poor or absent deaths that could have been prevented occur
When quality of care is poor communities may be discouraged from promptly taking patients even when the capacity exists to transport patients
The 2 General Types of EMS Systems
Anglo-American system Franco-German system
ldquoScoop and Runrdquo ldquoStay and Playrdquo
Prehospital care by
paramedics
Prehospital care by
Emergency physicians
Patients delivered to hospital-based
AED staffed by EP
Patients delivered directly
to inpatient services
(ACS Stroke MultiTrauma)
Bring the patient to the doctorrdquo Bring the doctor to the patientrdquo
May just transfer problems
to the nearest hospital
May take more time onndashthe-scene Cost +++
models in Europe Franco-German (60 ) vs Anglo American (30 )
Countries Utilizing the
American-Anglo EMS System Type
bull USA
bull Canada
bull United Kingdom
bull Ireland
bull Australia
bull Hong Kong
bull Mexico
bull South Korea
bull Iran
European Countries Physicians Provide
most Prehospital Care
bull France
bull Germany
bull Austria
bull Russia
bull Ukraine
bull Italy
bull Spain
bull Poland
bull Estonia
bull Croatia
bull Slovenia
bull Switzerland
bull Hungary
bull Czech Republic
bull Slovakia
bull Portugal
bull hellip
Cardiovascular diseases Top Ndeg1 in the world
175 Million people killed by cardiovascular diseases 74 million people died ischaemic heart disease
67 million people died stroke
in 2012
Globalization of need for EMS
Number of Road traffic death rate
China gt 261000 deaths India 207000 Nigeria 35000 US 34000 Russia 27000 Turkey 6687
httpgamapserverwhointghointeractive_chartsroad_safetyroad_traffic_deathsatlashtml
New Terrorist Threat
bull Adequate preparation bull rapid logistical response bull short transport times bull immediate access to OR bull methodical multidisciplinary care bull Military Medicinehellip
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
EMS amp EM amp EMTs amp EPs
bull Definitions ndash EMS (Emergency Medical services) is the
emergency care in the pre- or out-of-hospital setting by bull EMTs = Emergency Medical Technician bull Paramedics = highest level of EMT
ndash Levels vary within and between countries ndash Up to 5 years of training
bull Nurses or doctors
ndash Working on ambulances helicopters HEMS Helicopter Emergency Medical Services (UK HK Germany Canada France Japan Australiahellip)
Myth ldquoEmergency care is expensiverdquo
EM amp EMS
In many countries Emergency Medicine is EMS
ndash Physicians are on ambulances
bull But are these really Eps
ndash And subspecialists are in the ED
bull (eg surgeons pneumonologists etc) see their own patients in a common ED or in separate specialty specific receiving areas
bull They are not really emergency physicians
What is the objective of EMS
1 Life-threatening injuries are appropriately treated promptly to maximize survival
2 Potentially disabling injuries are treated appropriately to minimize functional impairment
3 Minimize Pain and psychological suffering
EMS
Prehospital Care
Emergency Department
Transport
Varies from country to country Should be linked to Health Facilities
When pre-hospital transportation is poor or absent deaths that could have been prevented occur
When quality of care is poor communities may be discouraged from promptly taking patients even when the capacity exists to transport patients
The 2 General Types of EMS Systems
Anglo-American system Franco-German system
ldquoScoop and Runrdquo ldquoStay and Playrdquo
Prehospital care by
paramedics
Prehospital care by
Emergency physicians
Patients delivered to hospital-based
AED staffed by EP
Patients delivered directly
to inpatient services
(ACS Stroke MultiTrauma)
Bring the patient to the doctorrdquo Bring the doctor to the patientrdquo
May just transfer problems
to the nearest hospital
May take more time onndashthe-scene Cost +++
models in Europe Franco-German (60 ) vs Anglo American (30 )
Countries Utilizing the
American-Anglo EMS System Type
bull USA
bull Canada
bull United Kingdom
bull Ireland
bull Australia
bull Hong Kong
bull Mexico
bull South Korea
bull Iran
European Countries Physicians Provide
most Prehospital Care
bull France
bull Germany
bull Austria
bull Russia
bull Ukraine
bull Italy
bull Spain
bull Poland
bull Estonia
bull Croatia
bull Slovenia
bull Switzerland
bull Hungary
bull Czech Republic
bull Slovakia
bull Portugal
bull hellip
Cardiovascular diseases Top Ndeg1 in the world
175 Million people killed by cardiovascular diseases 74 million people died ischaemic heart disease
67 million people died stroke
in 2012
Globalization of need for EMS
Number of Road traffic death rate
China gt 261000 deaths India 207000 Nigeria 35000 US 34000 Russia 27000 Turkey 6687
httpgamapserverwhointghointeractive_chartsroad_safetyroad_traffic_deathsatlashtml
New Terrorist Threat
bull Adequate preparation bull rapid logistical response bull short transport times bull immediate access to OR bull methodical multidisciplinary care bull Military Medicinehellip
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
EM amp EMS
In many countries Emergency Medicine is EMS
ndash Physicians are on ambulances
bull But are these really Eps
ndash And subspecialists are in the ED
bull (eg surgeons pneumonologists etc) see their own patients in a common ED or in separate specialty specific receiving areas
bull They are not really emergency physicians
What is the objective of EMS
1 Life-threatening injuries are appropriately treated promptly to maximize survival
2 Potentially disabling injuries are treated appropriately to minimize functional impairment
3 Minimize Pain and psychological suffering
EMS
Prehospital Care
Emergency Department
Transport
Varies from country to country Should be linked to Health Facilities
When pre-hospital transportation is poor or absent deaths that could have been prevented occur
When quality of care is poor communities may be discouraged from promptly taking patients even when the capacity exists to transport patients
The 2 General Types of EMS Systems
Anglo-American system Franco-German system
ldquoScoop and Runrdquo ldquoStay and Playrdquo
Prehospital care by
paramedics
Prehospital care by
Emergency physicians
Patients delivered to hospital-based
AED staffed by EP
Patients delivered directly
to inpatient services
(ACS Stroke MultiTrauma)
Bring the patient to the doctorrdquo Bring the doctor to the patientrdquo
May just transfer problems
to the nearest hospital
May take more time onndashthe-scene Cost +++
models in Europe Franco-German (60 ) vs Anglo American (30 )
Countries Utilizing the
American-Anglo EMS System Type
bull USA
bull Canada
bull United Kingdom
bull Ireland
bull Australia
bull Hong Kong
bull Mexico
bull South Korea
bull Iran
European Countries Physicians Provide
most Prehospital Care
bull France
bull Germany
bull Austria
bull Russia
bull Ukraine
bull Italy
bull Spain
bull Poland
bull Estonia
bull Croatia
bull Slovenia
bull Switzerland
bull Hungary
bull Czech Republic
bull Slovakia
bull Portugal
bull hellip
Cardiovascular diseases Top Ndeg1 in the world
175 Million people killed by cardiovascular diseases 74 million people died ischaemic heart disease
67 million people died stroke
in 2012
Globalization of need for EMS
Number of Road traffic death rate
China gt 261000 deaths India 207000 Nigeria 35000 US 34000 Russia 27000 Turkey 6687
httpgamapserverwhointghointeractive_chartsroad_safetyroad_traffic_deathsatlashtml
New Terrorist Threat
bull Adequate preparation bull rapid logistical response bull short transport times bull immediate access to OR bull methodical multidisciplinary care bull Military Medicinehellip
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
What is the objective of EMS
1 Life-threatening injuries are appropriately treated promptly to maximize survival
2 Potentially disabling injuries are treated appropriately to minimize functional impairment
3 Minimize Pain and psychological suffering
EMS
Prehospital Care
Emergency Department
Transport
Varies from country to country Should be linked to Health Facilities
When pre-hospital transportation is poor or absent deaths that could have been prevented occur
When quality of care is poor communities may be discouraged from promptly taking patients even when the capacity exists to transport patients
The 2 General Types of EMS Systems
Anglo-American system Franco-German system
ldquoScoop and Runrdquo ldquoStay and Playrdquo
Prehospital care by
paramedics
Prehospital care by
Emergency physicians
Patients delivered to hospital-based
AED staffed by EP
Patients delivered directly
to inpatient services
(ACS Stroke MultiTrauma)
Bring the patient to the doctorrdquo Bring the doctor to the patientrdquo
May just transfer problems
to the nearest hospital
May take more time onndashthe-scene Cost +++
models in Europe Franco-German (60 ) vs Anglo American (30 )
Countries Utilizing the
American-Anglo EMS System Type
bull USA
bull Canada
bull United Kingdom
bull Ireland
bull Australia
bull Hong Kong
bull Mexico
bull South Korea
bull Iran
European Countries Physicians Provide
most Prehospital Care
bull France
bull Germany
bull Austria
bull Russia
bull Ukraine
bull Italy
bull Spain
bull Poland
bull Estonia
bull Croatia
bull Slovenia
bull Switzerland
bull Hungary
bull Czech Republic
bull Slovakia
bull Portugal
bull hellip
Cardiovascular diseases Top Ndeg1 in the world
175 Million people killed by cardiovascular diseases 74 million people died ischaemic heart disease
67 million people died stroke
in 2012
Globalization of need for EMS
Number of Road traffic death rate
China gt 261000 deaths India 207000 Nigeria 35000 US 34000 Russia 27000 Turkey 6687
httpgamapserverwhointghointeractive_chartsroad_safetyroad_traffic_deathsatlashtml
New Terrorist Threat
bull Adequate preparation bull rapid logistical response bull short transport times bull immediate access to OR bull methodical multidisciplinary care bull Military Medicinehellip
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
EMS
Prehospital Care
Emergency Department
Transport
Varies from country to country Should be linked to Health Facilities
When pre-hospital transportation is poor or absent deaths that could have been prevented occur
When quality of care is poor communities may be discouraged from promptly taking patients even when the capacity exists to transport patients
The 2 General Types of EMS Systems
Anglo-American system Franco-German system
ldquoScoop and Runrdquo ldquoStay and Playrdquo
Prehospital care by
paramedics
Prehospital care by
Emergency physicians
Patients delivered to hospital-based
AED staffed by EP
Patients delivered directly
to inpatient services
(ACS Stroke MultiTrauma)
Bring the patient to the doctorrdquo Bring the doctor to the patientrdquo
May just transfer problems
to the nearest hospital
May take more time onndashthe-scene Cost +++
models in Europe Franco-German (60 ) vs Anglo American (30 )
Countries Utilizing the
American-Anglo EMS System Type
bull USA
bull Canada
bull United Kingdom
bull Ireland
bull Australia
bull Hong Kong
bull Mexico
bull South Korea
bull Iran
European Countries Physicians Provide
most Prehospital Care
bull France
bull Germany
bull Austria
bull Russia
bull Ukraine
bull Italy
bull Spain
bull Poland
bull Estonia
bull Croatia
bull Slovenia
bull Switzerland
bull Hungary
bull Czech Republic
bull Slovakia
bull Portugal
bull hellip
Cardiovascular diseases Top Ndeg1 in the world
175 Million people killed by cardiovascular diseases 74 million people died ischaemic heart disease
67 million people died stroke
in 2012
Globalization of need for EMS
Number of Road traffic death rate
China gt 261000 deaths India 207000 Nigeria 35000 US 34000 Russia 27000 Turkey 6687
httpgamapserverwhointghointeractive_chartsroad_safetyroad_traffic_deathsatlashtml
New Terrorist Threat
bull Adequate preparation bull rapid logistical response bull short transport times bull immediate access to OR bull methodical multidisciplinary care bull Military Medicinehellip
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
The 2 General Types of EMS Systems
Anglo-American system Franco-German system
ldquoScoop and Runrdquo ldquoStay and Playrdquo
Prehospital care by
paramedics
Prehospital care by
Emergency physicians
Patients delivered to hospital-based
AED staffed by EP
Patients delivered directly
to inpatient services
(ACS Stroke MultiTrauma)
Bring the patient to the doctorrdquo Bring the doctor to the patientrdquo
May just transfer problems
to the nearest hospital
May take more time onndashthe-scene Cost +++
models in Europe Franco-German (60 ) vs Anglo American (30 )
Countries Utilizing the
American-Anglo EMS System Type
bull USA
bull Canada
bull United Kingdom
bull Ireland
bull Australia
bull Hong Kong
bull Mexico
bull South Korea
bull Iran
European Countries Physicians Provide
most Prehospital Care
bull France
bull Germany
bull Austria
bull Russia
bull Ukraine
bull Italy
bull Spain
bull Poland
bull Estonia
bull Croatia
bull Slovenia
bull Switzerland
bull Hungary
bull Czech Republic
bull Slovakia
bull Portugal
bull hellip
Cardiovascular diseases Top Ndeg1 in the world
175 Million people killed by cardiovascular diseases 74 million people died ischaemic heart disease
67 million people died stroke
in 2012
Globalization of need for EMS
Number of Road traffic death rate
China gt 261000 deaths India 207000 Nigeria 35000 US 34000 Russia 27000 Turkey 6687
httpgamapserverwhointghointeractive_chartsroad_safetyroad_traffic_deathsatlashtml
New Terrorist Threat
bull Adequate preparation bull rapid logistical response bull short transport times bull immediate access to OR bull methodical multidisciplinary care bull Military Medicinehellip
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
Countries Utilizing the
American-Anglo EMS System Type
bull USA
bull Canada
bull United Kingdom
bull Ireland
bull Australia
bull Hong Kong
bull Mexico
bull South Korea
bull Iran
European Countries Physicians Provide
most Prehospital Care
bull France
bull Germany
bull Austria
bull Russia
bull Ukraine
bull Italy
bull Spain
bull Poland
bull Estonia
bull Croatia
bull Slovenia
bull Switzerland
bull Hungary
bull Czech Republic
bull Slovakia
bull Portugal
bull hellip
Cardiovascular diseases Top Ndeg1 in the world
175 Million people killed by cardiovascular diseases 74 million people died ischaemic heart disease
67 million people died stroke
in 2012
Globalization of need for EMS
Number of Road traffic death rate
China gt 261000 deaths India 207000 Nigeria 35000 US 34000 Russia 27000 Turkey 6687
httpgamapserverwhointghointeractive_chartsroad_safetyroad_traffic_deathsatlashtml
New Terrorist Threat
bull Adequate preparation bull rapid logistical response bull short transport times bull immediate access to OR bull methodical multidisciplinary care bull Military Medicinehellip
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
European Countries Physicians Provide
most Prehospital Care
bull France
bull Germany
bull Austria
bull Russia
bull Ukraine
bull Italy
bull Spain
bull Poland
bull Estonia
bull Croatia
bull Slovenia
bull Switzerland
bull Hungary
bull Czech Republic
bull Slovakia
bull Portugal
bull hellip
Cardiovascular diseases Top Ndeg1 in the world
175 Million people killed by cardiovascular diseases 74 million people died ischaemic heart disease
67 million people died stroke
in 2012
Globalization of need for EMS
Number of Road traffic death rate
China gt 261000 deaths India 207000 Nigeria 35000 US 34000 Russia 27000 Turkey 6687
httpgamapserverwhointghointeractive_chartsroad_safetyroad_traffic_deathsatlashtml
New Terrorist Threat
bull Adequate preparation bull rapid logistical response bull short transport times bull immediate access to OR bull methodical multidisciplinary care bull Military Medicinehellip
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
Cardiovascular diseases Top Ndeg1 in the world
175 Million people killed by cardiovascular diseases 74 million people died ischaemic heart disease
67 million people died stroke
in 2012
Globalization of need for EMS
Number of Road traffic death rate
China gt 261000 deaths India 207000 Nigeria 35000 US 34000 Russia 27000 Turkey 6687
httpgamapserverwhointghointeractive_chartsroad_safetyroad_traffic_deathsatlashtml
New Terrorist Threat
bull Adequate preparation bull rapid logistical response bull short transport times bull immediate access to OR bull methodical multidisciplinary care bull Military Medicinehellip
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
Globalization of need for EMS
Number of Road traffic death rate
China gt 261000 deaths India 207000 Nigeria 35000 US 34000 Russia 27000 Turkey 6687
httpgamapserverwhointghointeractive_chartsroad_safetyroad_traffic_deathsatlashtml
New Terrorist Threat
bull Adequate preparation bull rapid logistical response bull short transport times bull immediate access to OR bull methodical multidisciplinary care bull Military Medicinehellip
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
Number of Road traffic death rate
China gt 261000 deaths India 207000 Nigeria 35000 US 34000 Russia 27000 Turkey 6687
httpgamapserverwhointghointeractive_chartsroad_safetyroad_traffic_deathsatlashtml
New Terrorist Threat
bull Adequate preparation bull rapid logistical response bull short transport times bull immediate access to OR bull methodical multidisciplinary care bull Military Medicinehellip
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
New Terrorist Threat
bull Adequate preparation bull rapid logistical response bull short transport times bull immediate access to OR bull methodical multidisciplinary care bull Military Medicinehellip
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
1 Care provide in the community until the patient arrives at ED
2 Basic strategies with proven effectiveness ndash rapid transportation
ndash Triage
ndash prioritize treatment (hypoglycemia asthmahellip)
ndash transfer
ndash mainly by non physicians
ndash Invasive procedures (IV fluids NIVIntubation) performed by physicians
Pre hospital care
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
Pre-hospital care resources
Pre-hospital
1st Responders motivated citizens who are more likely to confront emergency situations
Little literature (Iraq Cambodia) significant reduction in mortality
from injury among populations with a high prevalence of injury
Paramedics US UK CanadaIreland Australia HK Mexico
Using ambulances and equipment BLS 1 team 50 000 people Average Response time 4-6 mn Mexico1 team 100 000 ART 10 minutes Hanoi (Viet Nam) 1 team 600 000 ART 30 minutes
most middle-income countries and some cities in low-income countries
sub-Saharan Africa and Asia paramedical personnel (ambulances)
are used only to transfer patients between health facilities
and not from the scenes of injury or from their homes
There is no evidence to support training paramedics in ALS
Physicians France Italy Spain
Not always feasible in low-income countries if trained personnel are few and if make round-the-clock coverage costs are difficult
Invasive procedures (IV fluids NIVIntubation) performed by
physicians do not necessary improve outcome
Bulletin of the World Health Organization August 2005 83 (8)
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
Ex management of airways In prehospital vs in-hospital conditions
Prehospital (8) ED
Cardiac arrest CPR (30-45) Cardiac arrest (10)
Neurologic disorders (stroke status epilepticushellip)
Stroke Status epilepticus (30 )
Intoxications Intoxications (20 )
Trauma polytrauma (10-15 ) Respiratory distress
Burns Trauma (US)
ETI in 15398 pts 2536 physicians (RSI) 12862 non-physician
Failed ETI Physicians 1 100 Non-physicians 15 100
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
On-the scene pre-hospital Damage Control resuscitation and Tactical Combat Casualty care
bull Extraction to safe zone bull External hemorrhage compression
tourniquets bull Shock with hypotension objective maintain
BP gt 60 mmHg bull Antifibrinolytics agents tranexamic Acid= 1g
20 min bull Waiting positionControl Hypothermia bull Oxygenotherapy avoid intubationventilation bull Limit analgesia bull fastest possible haemostatic surgery
Evacuation to the closer OR lt 60 mn max
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
Overcrowding a Worldwide problemhellip
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
14
European ED and overcrowding
University 82 Regional 85 District 77 General 66 Private 26 (AUTBELCYPGERMATPOLSPA)
Triage Protocols Standardized (89 ) MTS at national level (30) Computer recording (35)
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
0
200
400
600
800
1000
1200
Turkey Canada USA England France Germany
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
The Hospital ED must have
1 24-hour open access to all acute care
2 Robust Triage system
3 Treatment of patients with life threatening situations within 10 minutes
4 A short stay frasl overnight area monitor patients before final decision-making
5 provide for a maximum of 24 hours of care
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
1 EDs should be staffed with sufficient human resources to provide quality care
2 Staff numbers based on target (eg doctor frasl nurse per number of patients frasl population served)
3 Working hours should be divided into day and night shifts of no more than 12 hours
Synopsis of Consensus Statements on Staffing of EDs in Developing Countries
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
bull Triage
bull recognition of signs and symptoms in acute situations
bull life-saving care in the initial stages
bull assisting doctors with procedures
bull safe patient transport and movement
bull cast placement suturing of wounds
bull nebulization intravenous access
Specific roles for non physicians in the ED in developing countries
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
1 Treatment including initial management and stabilization resuscitation of unstable patients
2 Diagnosis
3 pathway to a specialist center
4 Manage short-term patients to control hospital admissions
5 minimize suffering and reduce mortality and morbidity
The Hospital ED must have
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
INPUT
THROUGHPUT
OUTPUT (Med Surgical Ward)
non URGENT
Level 234 Level 1
VITAL DISTRESS
70- 80
GP Primary Care
POC CT in ED
Bed Management
Fast Track
(EU US GCC)
Coordination GP Hospital Walk in Center (Netherlands Denmark Sweden)
TEMPORARY BEDS UNIT
Internist Geriatric Palliative
Team (Spain France)
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
MSTUs significantly reduced numerous time intervals along the emergency stroke care continuum in comparison to controls bull dispatch to door (19min vs 31min p=003) bull door to initial CT (12min vs 32min p=001) bull CT to IAT (82min vs 165min p=001)
IAT intra-arterial therapy
Germany US
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
Prehospital telemedicine system to support paramedics
Bergrath et al Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2013 21 54 httpwwwsjtremcomcontent21154
Sweden
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
Transportation of SAD weight 4kg Speed 100 kmh area 20 km2
Italy
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
Conf Proc IEEE Eng Med Biol Soc 2015 Aug2015315-8 doi 101109EMBC20157318363 Live ECG readings using Google Glass in emergency situations Schaer R
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
bull
bull
bull
bull
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
Predictions for next 10-20 years
ndash IT and Telemedicine will help put us at the bedside
ndash Increasing deployment of systems to improve diagnosis and reduce errors
ndash Continued refinement and evolution of technology
ndash Easier involvement of other specialists in the ED
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
Summary
bull EMSprehospital care ndash Needs to be organized
bull To deliver a SYSTEM of emergency care
ndash Needs to be represented bull To argue improved care
bull EMSprehospital care ndash needs to do research
ndash needs to provide continuing education
