EM in Slovenia Andrej Zmavc

• C3_09 ID 210

Slovenia - Country information 1

• Slovenia is a small middle European country, situated at the top corner of the Adriatic sea; the longest diameter is 400 km

• It borders to Italy on the west, to Austria on the north, to Hungary on the east and to Croatia on the south.

• It used to be the most developed part of the former Yugoslavia; independence attained in 1991.

Slovenia - Country information 2

• Heterogeneous climate/geographic regions within a short distance

• Alpine, Panonian, Continental, Karst, Mediterranean environment

Slovenia - Population 1

• 2 million• Disperse settlement, only two cities bigger than

100.000• >90% Slovene nationality• Ageing population, current life expectancy F 75, M

67; active-retired ratio estimation for year 2015 = 1:1

• Typical European socio-economic structure; GDP $7000

• Obligatory health insurance (almost 100% of pop.)• Health care budget = 8%GDP + 1% other

resources

Slovenia - Population 2

• Major morbidity & mortality problems: Cardiovascular, Cancer, Trauma

• High rate of alcoholism, traffic accidents, suicide

Slovenia - Health care system 1

• Dense net of Community health care centers CHCC (basic institutions of primary health care system), well developed primary HCS

• 10 general hospitals, 2 university hospitals• Since 1991 no major changes in structure of

HCS (in type and number of institutions)• Changes in funding system - Establishment of

the National health insurance company in 1992

• Establishing the private practice

Slovenia - Health care system 2

• A uniform nationwide health care system conducted by the Ministry of health, medical supervision by the Medical chamber, funded by the National health insurance co.

• All hospitals are public, private practices in primary HCS (30% general/family physicians, 70% dentists)

Slovenia - Health care system - primary health care

• Community health care center (CHCC) - the basic primary HC institution

• CHCC encompasses: general/family medicine, pediatric and school medicine, occupational medicine, stomathology, physiotherapy, home nursing care, patient transportation (ambulances), etc.

• Bigger CHCC have as well some specialistic services (gynaecology, psychiatry, pulmology, dermatology, etc.) and prehospital EMS units

Slovenia - Health care system - education

• Physicians: 6y medical faculty, 2y obligatory postgraduate clinical training (6m emergency medicine), 2-4y specialisation

• All physicians must have a licence to work with patients (renewal each 7y - Medical chamber)

• Medical technicians - nurses: 4y medical school, 6m practice, optionally 3y nursing faculty

Slovenia - Health care system - EM speciality status

• No specialty in EM• Prehospitaly - physicians specialists in GM/FM

with additional training in EM• Hospitaly - each speciality care for own

patients • The process of introducing a license for EM

and the first steps of putting up an EM speciality has started

• Activities in organisation of emergency departments in bigger hospitals

Slovenia - Health care system - professional orgs concerned for EM

• Pre-hospital: The project of EMS (Ministry of health), CHCC, Society for EM

• In-hospital: The project of EMS (Ministry of health), hospitals, Society for EM

Slovenia - EM System information - the basics

• EM care should be available to every person in need regardless of his/hers insurance status

• Each physician must (by the law) offer first medical aid

• Each CHCC and hospital must provide EM care as a part of its regular activity

• All EMS system is public

Slovenia - EM - Prehospital system 1

• All prehospital EMS system is based on primary health care facilities

• Prehospital EMS units (62 of them) are situated and organized within CHCC

• Generally there are two types of prehospital EMS units• City PEMS units• Peripheral EMS units

Slovenia - EM - Prehospital system 2

• City PEMS units• Most of the units located nearby hospital• EM team: trained physician, 2 trained

technicians• 24-hour service for emergencies only• EM technician-dispatcher (optionally)

• Peripheral EMS units• No special EM team• GP/FP on duty, med. technician, rescuer-driver• EMS is part of the regular activity of GP/FP

Slovenia - EM - Prehospital system / Funding

• The whole prehospital EMS system is on a fixed yearly budged

• cost-effectiveness• estimation for the system once fully

developed = 15 mill EUR/year• currently the cost is 10 mill. EUR/year

• 350 EUR/intervention; 5 EUR/inhabitant/year

Slovenia - EM - Prehospital system / Performance

• All units / year 2002• population ................... 2.000.000• patients ....................... 26.800• interv./1000 pop. ......... 13,4• mean response time ... 10,9 min• CPR ............................ 766 (2,9%)

• ROSC ..................... 233 (30,4%)• survivors ................. 93 (12,1%)

• ET intubations ............. 822 (3,1%)• ETI/CPR ratio .............. 1,1• dead at arrival ............. 1125 (4,2%)

Slovenia - EM - Prehospital system / Performance

• Peripheral units only / year 2002• population ................... 688.000• patients ....................... 9.630• interv./1000 pop. ......... 14,0• mean response time ... 13,7 min• CPR ............................ 227 (2,4%)

• ROSC ..................... 46 (20%)• survivors ................. 11 (4,8%)

• ET intubations ............. 182 (1,9%)• ETI/CPR ratio .............. 0,8• dead at arrival ............. 391 (4,1%)

Slovenia - EM - Prehospital system / Performance

• Three most developed city units / year 2002• population ................... 595.000• patients ....................... 5.525• interv./1000 pop. ......... 9,3• mean response time ... 9,0 min• CPR ............................ 282 (5,1%)

• ROSC ..................... 118 (41,8%)• survivors ................. 52 (18,4%)

• ET intubations ............. 397 (7,2%)• ETI/CPR ratio .............. 1,4• dead at arrival ............. 346 (6,2%)

Slovenia - EM - Hospital care

• 10 general hospitals; 2 university hospitals • No emergency departments• Patients usually transferred to local hospitals• each speciality treats its own patients• no special funding for EM care in hospitals

until now• recently established “one day hospital” - the

beginning of ED?

Slovenia - EM - The top challenges 1

• Education/qualification of prehospital providers• huge difference in qualification• no standardised education for EM

• solution: a licence for prehospital EMS• specialisation in EM

• Insufficient EMS in rural areas• the shortage of physicians in rural areas• small number of emergency interventions

• centralisation of service wherever feasible

Slovenia - EM - The top challenges 2

• Establishment of ED in bigger hospitals• closer co-operation with city PEMS units• specialisation in EM

• unification/improving effectiveness of admission and initial EM care in smaller hospitals

Slovenia EM - Summary 1

• Small country, relatively old population, very limited budged for health care system

• Well developed public health care system• Well developed primary HCS• Dense net of Community Health Care Centres

(CHCC)• Mostly sufficient hospital capacity

Slovenia EM - Summary 2

• Organization of prehospital EMS within primary health care system• cost-effectiveness

• City prehospital EMS units - variable performance mostly effective

• Peripheral (rural) units mostly insufficient• Hospital EM care more or less sufficient -

could be better• Improvement proposed trough the

establishment of ED in bigger hospitals

Slovenia EM - Summary 3

• Need for improvement in education/skills of prehospital providers• Standardization - Licences; Specialization

in EM• More tight connection between hospitals and

city PEMS units• Additional funding resources besides the

budged for prehospital EMS

EM in Slovenia - Conclusion

• Improving EM by:• the Project of EMS in Slovenia - Ministry of

health• active co-operation of all relevant

institutions: Society for EM, Medical chamber, Ministry of health, National health insurance co.

• organising of ED within the existed hospital structure (minimal investment)

• a little help of enthusiastic individuals devoted to EM