The German Rescue System with a
Focus on Trauma C. Waydhas University Hospital Essen
Geographical Facts Mongolia Area
1.564.116
Population Urban population Population density
km2
Germany 357.021 km2
2.95 million
81,1 million
40 %
89%
1,9 /
km2
227 / km2
Titel
Trauma Surgery, University Hospital Essen
1
Urgency and Emergency • Doctors on-call („Ärztlicher Notdienst“) Tel. 116117 Diseases or conditions that require urgent treatment (within hours) but are not life-threatening, provided mostly by general practitioners and internists
• Emergency Medical Service („Rettungsdienst“) Tel. 112 Diseases or conditions that are life-threatening and require emergent treatment (within minutes or less than an hour). New: eCall (starting by 2018)
paramedics
(prehospital) emergency physicians Titel
Trauma Surgery, University Hospital Essen
Dispatch Center
Decision which type of rescue vehicle (emergency physician required or not)
Decision which specific vehicle Rescue time < 8 to 15 minutes (>95% of cases) Titel
Trauma Surgery, University Hospital Essen
2
Qualification of Emergency Physicians • 24 months of training (patient-centered, in-hospital, acute care) • 6 months of training in intensive care, anaesthesiology or emergency department • 80 hours course in emergeny care • 50 accompanied missions in ground or air ambulance (with physician)
Specific skills and knowledge • Endotracheal intubation (≥25) • Manual/mechanical ventilation • cardio-pulmonary reanimation
• Intravenous access (≥50) • Chest tube insertion ( ≥2) Titel
Trauma Surgery, University Hospital Essen
• ..........
Corner Points for the emergency care of the German population A definite treatment of major emergency conditions such as STEMI (ST-elevation myocardial infarction): PCI Stroke: decision for lysis Severe traumatic brain injury: start of surgery Polytrauma: start of surgery should be achieved/started within 90 min To attain this goal it has to be aimed at an intervall between the emergency call and admission to the (appropriate) hospital of less than 60 minutes German Medical Association 2007 and 16 Medical Societies
Titel
Trauma Surgery, University Hospital Essen
3
Corner Points for the emergency care of the German population
Consequences: • Appropriate structure and organisation of the prehospital rescue system • Appropriate medical priorities of the amublance team • Appropriate structure and organisation of the emergency room in the hospital German Medical Association 2007 and 16 Medical Societies
Titel
Trauma Surgery, University Hospital Essen
Air Rescue Helicopter Service •
Primary Rescue
•
Secondary transfer, critically ill patients
Titel
Trauma Surgery, University Hospital Essen
4
Availability of Hospitals Traffic accidents (died/survived(%))
Area (km2) per Hospital
Area (km2) per helicopter
Mecklenburg
2.7
4634
7724
Brandenburg
2.4
5895
9825
Thüringen
2.3
1470
5390
Sachsen-Anh.
2.2
1858
20445
Niedersachsen
1.6
2506
9523
Sachsen
1.6
1673
6137
Bayern
1.6
1720
8818
Rheinland-Pf..
1.5
1653
6615
Baden-Wür.
1.4
1430
7150
Schleswig-Hol.
1.2
2251
7881
Hessen
1.2
1319
7038
Saarland
1.2
856
2568
NRW
1.1
541
4869
Berlin
0.5
89
891
Bremen
0.5
101
404
Hamburg
0.4
151
387
State
Road traffic statistics 2002
Titel
Trauma Surgery, University Hospital Essen
Availability of Hospitals Traffic accidents (died/survived(%))
Area (km2) per Hospital
Area (km2) per helicopter
2.7
4634
7724
2.4
5895
9825
Thüringen
2.3
1470
5390
Sachsen-Anh.
2.2
1858
20445
Niedersachsen
1.6
2506
9523
Sachsen
1.6
1673
6137
Bayern
1.6
1720
8818
Rheinland-Pf..
1.5
1653
6615
Baden-Wür.
1.4
1430
7150
Schleswig-Hol.
1.2
2251
7881
Hessen
1.2
1319
7038
Saarland
1.2
856
2568
NRW
1.1
541
4869
Berlin
0.5
89
891
Bremen
0.5
101
404
Hamburg
0.4
151
387
State Mecklenburg Brandenburg
2,7
Road traffic statistics 2002 Verkehrsunfallstatistik 2002Titel Trauma Surgery, University Hospital Essen
5
Availability of Hospitals Road traffic accidents mortality (%)
Area (km2) per Hospital
Area (km2) per helicopter
2.7
4634
7724
2.4
5895
9825
Thüringen
2.3
1470
5390
Sachsen-Anh.
2.2
1858
20445
Niedersachsen
1.6
2506
9523
Sachsen
1.6
1673
6137
Bayern
1.6
1720
8818
Rheinland-Pf..
1.5
1653
6615
Baden-Wür.
1.4
1430
7150
Schleswig-Hol.
1.2
2251
7881
Hessen
1.2
1319
7038
Saarland
1.2
856
2568
NRW
1.1
1,1
541
4869
0.5
89
891
Bremen
0.5
101
404
Hamburg
0.4
151
387
State Mecklenburg
2,7
Brandenburg
Berlin
Road traffic statistics 2002 Verkehrsunfallstatistik 2002Titel Trauma Surgery, University Hospital Essen
Causes of Mortality in Germany
Diseases of the heart and the vascular system myocardial infarction Cancer Diseases of the respiratory system Diseases of the GI-tract Injuries
Titel
Trauma Surgery, University Hospital Essen
6
Causes of Mortality in Mongolia
78/100.000
Cardiovascular: 380/100.000 Cancer: 206/100.000 Injury: 78/100.000 Titel
Trauma Surgery, University Hospital Essen
Leading cause of death in age group 25-44yrs WHO/OECD Report Asia 2012
Lost Years in Work (*1000) neurological d. Neurol. Erkrank. GI-tract Verdauungstrakt respiratory syst. Atemorgane heart/circulation Herz-Kreislauf musculo/skelet. Muskulo-skelet. malignacies Neoplasie psychiatric d. Psych. Erkrank. injuries Verletzungen 0
200
Titel
400
600
800
1000
Federal Statistical Office 2008; www.destatis.de
Trauma Surgery, University Hospital Essen
7
Causes of Trauma Mortality
TBI: Bleeding: MOF:
Titel
Trauma Surgery, University Hospital Essen
67% 25% 8%
Soreide et al., World J Surg 2007
Medical Errors in Trauma Care „Lessons Learned From 2594 Deaths“
Titel
Trauma Surgery, University Hospital Essen
Gruen et al, Ann Surg 2006
8
Trauma-Center Approach • Local Trauma Center • Regional Trauma Center • Supraregional Trauma Center
Titel
Trauma Surgery, University Hospital Essen
Trauma-Center Approach
50 TraumaNetworks with 557 Trauma Centers (certified) Re-Audit every 3 years Titel
Trauma Surgery, University Hospital Essen
9
White Book of Trauma Care Defines: •
Structural requirements
•
Personnel requirements
•
Organisational requirements
•
Networking between trauma centers
•
Quality Management
Titel
Trauma Surgery, University Hospital Essen
Polytrauma Guideline Update 2015 Prehospital:
•
Prehospital Phase
•
Emergency / Shock Room Phase
•
First Operation Phase
•
Airway Management
•
Volume Therapy
•
Analgesia
•
Chest Trauma
•
Head Injury
•
Spinal Trauma
•
Extremity Trauma
•
Mass Casualty
Titel
Trauma Surgery, University Hospital Essen
10
American College of Surgeons
Advanced Trauma Life Support for Doctors Titel
Trauma Surgery, University Hospital Essen
Traumaregister •
Input (online-registry) of data (prehospital, emergency room, operation, intensive care unit, outcome)
•
Output of your performance compared with the average
www.traumaregister.de Titel
Trauma Surgery, University Hospital Essen
11
Traumaregister
www.traumaregister.de Titel
Trauma Surgery, University Hospital Essen
Traumaregister Injury severity vs. Length of stay
Titel
Trauma Surgery, University Hospital Essen
www.traumaregister.de
12
Traumaregister Observed vs. expected outcome
www.traumaregister.de Titel
Trauma Surgery, University Hospital Essen
Conclusions
• Physician-based ambulance concept • Specific training requirements for emergency physicians • System of geographical coverage for rescue vehicles and hospitals • Predefined structural and organisational requirements for trauma care Titel
Trauma Surgery, University Hospital Essen
13
