1. EM in Slovenia Andrej Zmavc C3_09 ID 210

2. 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.

3. Slovenia - Country information 2 Heterogeneous climate/geographic regions within a short distance Alpine, Panonian, Continental, Karst, Mediterranean environment

4. 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

5. Slovenia - Population 2 Major morbidity & mortality problems: Cardiovascular, Cancer, Trauma High rate of alcoholism, traffic accidents, suicide

6. 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

7. 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)

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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%)

17. 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%)

18. 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%)

19. 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?

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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