Organization of Trauma Care in the Netherlands

Christian van der Werken

Paris, May 30st, 2008
Geography & Demography The Netherlands

• Area of 41.000 square kilometers

• 1 / 13th of France
• Greatest distance between borders 150 miles
• 16.4 million inhabitants = 400 people / square kilometer
110 people / square kilometer in France
 Differences between countries

GNP Euro p.c. Healthcare Spen- Physicians Life

COUNTRY
x 1000 dings Euro p.c. p. 1000 c. expectancy

France 22,8 1460 3,37 80,6

Netherlands 23,3 1400 3,15 79,1

Austria 23,5 1330 3,38 79,2

Germany 22,0 1720 3,37 78,9
Switzerland 34,9 2480 3,61 80,6
United Kingdom 23,9 1080 2,30 78,7

United States 27,8 3805 2,56 78,0

The Netherlands in the 1980’s

• Lack of organized trauma care

• No centralized care for the multiple injured patient
• Dutch Trauma Society stipulated repeatedly the need for action
• Simultaneously major incidents attracted the political arena
to improve the organization of trauma care
Basic Concepts Reorganization Trauma Care

• Regionalization and concentration of trauma care

(Inclusive trauma system)
– Ambulance services
– Inception of geographically dispersed Trauma Centers
– Backup helicopter service for a nationwide network of
mobile medical teams
• National Trauma registry
• Education
– ATLS (Advanced Trauma Life Support)
– PHTLS (Pre Hospital Trauma Life Support)
– MIMMS (Major Incident Medical Management Support)
 Geography and Demography

• Over 100 hospitals

• All have an Emergency Service taking care for injured patients
• Virtually all have ATLS trained doctors and nurses
• Physical distance is never a problem
• Ambulance time is < 15 minutes and is everywhere reached
Except: - West - Frisian islands
- Urban conglomerations (traffic congestion)
 Prehospital Care

• Principally provided by ambulance personnel

• Crew:
– Specifically trained driver
– PHTLS trained paramedic (90 % is ICU or anesthesiology trained)
• Resuscitation of severe trauma and cardiac arrest:
– Hard neck collar
– Spine board
– Coniotomy
– Chest needle decompression
– Intubation (without muscle relax.)
– Defibrillation

• No permission to perform full anesthesia

• Generally accepted national standard protocols
 Emergency Response System

• Early on 80 (!) different ambulance care providers

• Now 26 regions with
- Central control room (dispatch or CPA)
- Full ambulance service
- Training and evaluation responsibility
• Contact by European emergency number: 112
• Coordination by CPA
• Legal obligation to reach the victim within 15 minutes after first call
Ambulance

SPREAD OVER THE COUNTRY:

202 ambulance stands

 Ambulance Service

• Responsibility qualification based

(nurse is sole responsible for all the actions taken)
• Registration through Individual Health Professions Act (BIG)
• Professional has to be authorized to perform medical actions
• Functionally independent
• Overall responsibility lays with the medical officer of the
ambulance service
 On site care

• Basic emergency care by paramedics

• Evolving knowledge shows the efficacy of “SCOOP AND RUN”
• In complicated cases or need for prolonged anesthesia, support
can be called in from a designated Mobile Medical Team
10 MMT’s by car / special minibus
 On site care

• Basic emergency care by paramedics

• Evolving knowledge shows the efficacy of “SCOOP AND RUN”
• In complicated cases or need for prolonged anesthesia, support
can be called in from a designated Mobile Medical Team

10 MMT’s by car / special minibus

4 MMT’s by helicopter
 Mobile Medical Team

• Four hospitals are providing a helicopter backup facility

• Trained medical specialist (anesthesiologist or trauma surgeon)
• Paramedic with special training
• Until the beginning of 2006 flying time was between 7 am and 7 pm
 Mobile Medical Team

• Four hospitals are providing a helicopter backup facility

• Trained medical specialist (anesthesiologist or trauma surgeon)
• Paramedic with special training
• Until the beginning of 2006 flying time was between 7 am and 7 pm
• Recently one night helicopter service was started as pilot study
 Mobile Medical Team doctor training

• Anesthesiology training (for surgeons)

• Surgical training (for anesthesiologists)
• ICET training
• Media training
• ATLS
• ACLS
• APLS
• Toxicology training
• Crew resource management
• Flight safety training
• Line check JAR-OPS
• Helicopter training
 Trauma Centers

• Since 1999 designation of 10 (later11) Trauma Centers

– 8 University hospitals
– 3 General teaching hospitals with neurosurgical facilities

• Adequate care for every trauma patient in the most suitable hospital
• Centralization of the care for the polytrauma patient for the best care
• Decision made by the ambulance or MMT crew
• Protocols and direction on which patients belong in which facility
are in place and are working well
 Exclusive Trauma System

patients

ISS > 16 p.
Dutch Trauma Centres
Dutch Trauma Centers
 Burn care in The Netherlands

• Three major Burn Centers (Rotterdam, Beverwijk and Groningen)

• Patients
– Burn body surface area of > 20 %
(children > 15 %)
– Burn in special area’s

•
– Combined trauma and burn
No relation with a university hospital
*
*
*
 Hospital Care in The Netherlands

• High standard of care

• Well trained specialists (ATLS generally accepted)
• Categorized care
- Trauma Centers (10%): highest level of care: polytrauma
- Large general hospitals (30%) without neurosurgery:
major trauma
- Restricted capacity for trauma care (60%): isolated injuries
• Care is well distributed over these facilities

Advanced
Trauma
Life
Support
 In Hospital Care in The Netherlands

• Alert before patient arrives by the CPA

• Internet transfer patient’s data and parameters
• Emergency room:
– Surgeon is in charge
– Team approach: surgeon (ATLS+), anesthesiologist (ATLS+),
neurologist, radiologist supported with trained emergency care
nurses
– Team on site when patient arrives
– Additional services available on demand
 In Hospital Care in The Netherlands

• Alert before patient arrives through the CPA

• Internet transfer data
• Emergency room:
– Surgeon is in charge
– Team approach: surgeon (ATLS+), anesthesiologist (ATLS+),
neurologist, radiologist supported with trained emergency care
nurses
– Team on site when patient arrives
– Additional services available on demand
• Crucial is the ongoing lack of ICU beds for trauma
 Trauma Care in The Netherlands

• Mainly provided by general surgeons

• 80 % of skeletal trauma is treated by (trained) general surgeons
• 20 % and most spine injuries are treated by orthopedic surgeons
• Training of general surgeons:
– Designated trauma rotation in last year of training
– Two years fellowship after registration as a general surgeon
 Trauma Care in The Netherlands

• Mainly provided by general surgeons

• 80% of skeletal trauma is treated by (trained) general surgeons
• 20 % and most of spine trauma is in the hands of orthopedic
surgeons
• Training of general surgeons:
– Designated trauma rotation in last year of training
– Two years fellowship after registration as a general surgeon
• Care funding through statewide obligatory insurance/”social security”
• Trauma Centers are funded through a special program
(0,5 million Euro per year) for organizational en logistic functions
• Helicopter Centers have additional funds for their service
 Polytrauma Care in The Netherlands

• 2500 - 4000 polytrauma patients (ISS > 16) / year

• 20 % helicopter MMT intervention
• 11Traumacenters
• 180 - 300 polytrauma patients per center / year
• 20 % in hospital mortality
 Wishes for the future

- Increase helicopter MMT services 4 6

- All helicopter MMTeams 24 x 7 operational
- Increase national ICU capacity

• Halve the number of trauma centers

• 547.000 square kilometers

• 64.5 million inhabitants

Response time to victim