Transcript 5th International Conference “Health Insurance in Transition”

TRACK H
Developing EMS in Bulgaria and
Promoting Emergency Medicine
as an Independent Specialty
Dr. Assen Geshev - Center for Emergency Medicine and
Accidents - Stara Zagora, Bulgaria
Prof. M. Milanov MD – National Institute for EM – Sofia
Maxim Gaidev MD – Ministry of Health
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Country
information
Bulgaria is situated in
the south - east part
of Europe, and in the
eastern part of the
Balkan Peninsular.
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General Information
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Territory - 110 993,6 km2
Population - 7 973 671
Capital - Sofia
Official language - Bulgarian
Political system - Parliamentary Republic
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Demographic data: (01.03.2001):
Population - 7 973 671
Men - 3 888 440
Population in towns - 5 500 695
Population growth - (%) – 5,1
Socio-economics
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Country information
- The economy in 2001
Actual growth of GDP (%) 5,8
GDP (thousand Lvs) 25 453 649
GDP per capita (USD) 1459
Budget surplus (% GDP) - 1,1
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Country information
Burden of disease
Life expectancy – 71.5 years
 Major causes of morbidity and mortality
Ischemic heart disease and Cerebrovascular disease
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Health care system
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GPs – all over the country
Regional hospitals with basic wards only and small number of beds
28 county hospitals
5 university hospitals
Several centers of national significance
Financing –by state budget and by NHIF, a small number of private
hospitals and medical centers
Medical education
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5 Medical Faculties
6 years of study
4-5 years residency programme according to specialty
Medical Specialty Board certification mechanism - still not introduced
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EM specialty status
In 1996 Emergency Medicine is declared an
independent specialty by Ministry of Health .
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A national residency programme based in the National
Institute of Emergency Medicine was developed and carried
out in five Academic Medical Centers
The first admission exams were carried out in 1997.
The duration of the programme is four years. During this time
the resident has to pass 8 theoretical terms with an exam at
the end of each.
Final specialty exam by the National Examination Committee at
the end of the residency programme
Special attention is paid to anesthesiology and intensive care,
cardiology, toxicology, pediatrics and surgery.
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Residency Programme in EM
Anesthesia and Intensive Care
Pediatrics
Surgery
Cardiology
Neurology and Neurosurgery
Toxicology
Orthopedics and Traumatology
Obstetrics and Gynecology
Pulmonology
Psychiatry
Ophthalmology
Organization of EM
Urology
Burns
Gastroenterology
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Total practice
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64 weeks
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Bulgarian Association of EM Physicians
In 1999 Bulgarian Association of EM Physicians was founded
The main goals of the association are:
To unite all the emergency physicians
To work on the public image of EM
To promote standard protocols in EM
To support physicians in their qualification and
scientific research
To support public education and training in EM
To help international collaboration in EM
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EM System information
Both Pre-hospital and In-hospital emergency
care is provided by 28 CEMA. Emergency
care is a state policy and is totally funded
by Ministry of Health.
At present time the national system for
Emergency Medical Care consists of:
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28 centers for emergency medicine
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1507 doctors and 2532 nurses
186 branches for emergency medicine
92 mobile intensive care units
251 mobile medical units
50 transport units
50 emergency departments
136 emergency sectors
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EM System information
Structure of CEMA
administrative unit
 dispatch center = regional coordination
center
 emergency department
 mobile intensive care units
 mobile medical units
 transport units
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Dispatch Center
(regional coordination center)
It is based in the administrative center of the county.
It has a computerized system for registering and recording the
phone calls on the unified emergency number 150 and creating a
data base of all missions on which mobile units are sent.
Radiocommunication system was at first introduced. Through the
years with the development of mobile technologies, and having in
mind the geographic characteristics of the country the system
was doubled by GPS with voice modules providing bi-directional
communication. Thus the communications between ambulances,
emergency departments and dispatch centers became safer.
The dispatchers in these centers are nurses supervised by a
physician 24 hours a day. Neither special training or requirements
are needed for the dispatchers, nor any protocols are followed.
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Mobile units are three types
mobile intensive care unit –
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crew - consist of a physician, a nurse and a driver.
qualification - both the physician and the nurse have
passed courses for ACLS, APLS and ATLS. The driver
has accomplished a course of BLS and helps the medical
staff.
equipment - the ambulances are large vans, equipped with
standard
resuscitation
drugs,
cervical
collars,
backboards, monitors, defibrillators, perfusion pumps,
respirators and communication devices. The mean
response time for such a unit is 3 to 9 minutes. These
units are usually sent to traffic and industrial accidents
or to patients at high risk.
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Mobile units are three types
mobile medical unit
crew- consists of a physician and a driver.
 qualification - the physician has passed courses
for ACLS, APLS and ATLS and the driver has
accomplished a course of BLS and helps the
medical staff.
 equipment - the ambulances have the same
design and are equipped as mobile intensive care
units. These units are dispatched to patients who
are not in life threatening situation and
resuscitation won’t be needed.
The mean
response time for such a unit is 6 to 12 minutes.
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Mobile units are of three types
transport unit
crew–a driver who has accomplished a course
of BLS
 obligations - provides emergency transport
of bioproducts and blood, and specialists
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between hospitals.
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Emergency Department
It is a part of the Emergency Center and not of the
hospital.
The emergency departments can use the diagnostic
facilities of the hospital – laboratory, X-ray, CT
scanner.
In major cities these departments usually have:
 room for resuscitation and intensive care – equipped
with monitors, respirators, defibrillators, ECGmachines and variety of emergency drugs.
 trauma room – where surgical activities are run, such
as sutures, immobilizations, extraction of foreign
bodies.
 some departments have specialized pediatric
sectors
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Challenges
To overcome the use of ED as a round a clock GP
 To introduce National Standards in EM
 To intoduce the credit system in Certification
doctors in EM
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Comparative Analysis of Bulgaria’s EMS
Features
Specialty systems
National organization
Residency Training
Board Certification
Official specialty
status
Underdeveloped
Developing
Mature
Bulgaria
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Academic EM
Specialty Journal
Research
Database
Subspecialty training
No
No
No
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes, clinical
No
No
Patient Care System
EM physicians
ED director
Prehospital care
Transfer system
Trauma system
Other physicians
Other physicians
Private car
No
No
EM residency trained
EM residency trained
EM physician, EMT
No
No
EM residency trained
EM residency trained
EM physician, EMT
Yes
Yes
EM residency
trained
EM physician,
EMT
Yes
Yes
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Summary
The number dialed for a medical emergency is 150. It is well
known and easy to dial from everywhere.
The usage of one tier system providing a physician at the
scene is a guarantee for an on-time highly qualified help and
gives a great chance of survival.
Absence of protocols does not unify the activities carried by
the emergency physicians not only at the accident scene but
at the ED as well.
The absence of a special training, standard protocols and
requirements needed for the dispatchers is lowering the
effectiveness of their work. It leads to a high percentage of
non emergency cases and more expenses.
Less then 1% of the population is trained in CPR and for any
type of emergency help. The community is not familiar with
what to expect from the ED.
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Summary
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Educating more people how to behave in emergency situations and well
managed public relations will be the next step ahead
Educating more people how to behave in emergency situations and well
managed public relations will be the next step ahead.
All the emergency services – Fire Department, Police and EMS have
different emergency numbers and the delay caused by having to dial
different numbers in emergency situation has been shown to delay the
response times of ambulances, police and fire department. On the other
hand being under different supervision all three emergency services do
not work in team. Making emergencies a teem effort and teaching
firemen and policemen how to act as first responders will help us in fight
for our patients.
A better payment and ways to fight the everyday stress in our work will
help too.
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