Emergency Medical Services WHITE PAPER SUSTAINABLE HOSPITALS Emergency Medical Services

INNOVATING BETTER LIFE

SUSTAINABLE HOSPITALS Emergency Medical Services WHITE PAPER SUSTAINABLE HOSPITALS Emergency Medical Services

About this white paper This white paper presents the Danish approach to a coherent Emergency Medical Service and includes a broad range of innovative solutions that contribute to providing life-saving emergency medical care to all citizens. It is part of a series of white papers that show how Danish solutions can contribute to increase efficiency in healthcare while empowering patients and staff. Danish healthcare innovation is not exclusive for the Danes: many years of global presence show that our healthcare products and solutions create value internationally. Danish ideas and products are used every day in hospitals, medical clinics, ambulances, and nursing homes across the world. We hope to inspire you and would like to invite you to Denmark to learn more about the Danish healthcare system. Photo credits Foreword: Flemming Leitorp Page 6: Kim Dahl Page 7: Falck Page 8: European Resuscitation Council Page 9: Falck Page 10: Top, Bo Lehm. Below, Anna Glavind. Page 11: Kim Dahl Page 12: EMS Copenhagen Page 13: Martin Damgård Page 14: Martin Damgård Page 15: Tonny Foghmar Page 16: Falck Page 17: Kim Ahlers Page 18: EMS Copenhagen Page 19: Left, Christian Als. Right, Ture Andersen Page 20: Tine Harden Page 21: Ture Andersen Page 22: Falck Editor in Chief Healthcare DENMARK, Anne Smetana, [email protected] Steering Committee Danish Ministry of Health, Tove Kjeldsen, [email protected] Danish Regions, Jakob Schelde Holde, [email protected] Emergency Medical Services Copenhagen, Freddy Lippert, [email protected] Emergency Medical Services, Central Denmark Region, Per Sabro Nielsen, [email protected] Falck, Kjeld Brogaard, [email protected] The Danish Chamber of Commerce, Katrina Feilberg Schouenborg, [email protected] Contributors Aarhus University Hospital, Department of Cardiology, Central Denmark Region, Christian Juhl Terkelsen, [email protected] Amphi Systems A/S, Peter Juul, [email protected] Capital Region of Denmark, Fredrik Folke, [email protected] Corti, Andreas Cleve, [email protected] Emergency Medical Dispatch Centre, Region of Southern Denmark, Kim Ahlers, [email protected] Emergency Medical Services Copenhagen, Kirstine Vestergård Nielsen, kirstine.vestergaard. [email protected], Christina Guldbrandt, [email protected], and Peter Berlac, [email protected] Emergency Medical Services, Central Denmark Region, Anna Glavind, [email protected] Emergency Medical Services, North Denmark Region, Peter Larsen, [email protected] Emergency Medical Services, North Denmark Region, Poul Anders Hansen, [email protected] Emergency Medical Services, Region Zealand, Benny Jørgensen, [email protected] FirstAED, Henrik Schakow, [email protected] KMD, Jesper Høgh Bager, [email protected], and Rene Hauge Sørensen, [email protected] Logis Solutions, René Munk Joergensen, [email protected] The Danish foundation Trygfonden, Grethe Thomas, [email protected] The National Emergency Medical Helicopter Organization, Svend Hartling, [email protected] Healthcare DENMARK’s partners :

EMS white paper version 1, January 2019

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Executive summary

During the past few decades, Emergency Medi- Modern ambulance equipment ensures seamless commu- cal Services (EMS) have come to play an increas- nication, including real-time transmission of data between ingly important role in the Danish healthcare ambulances and hospital departments. This allows emer- system. gency medical staff, both in the ambulance and at the receiving hospital, to make the best possible use of data The EMS has traditionally been regarded as a hospital from hospital and prehospital patient records and from ‘support function’, focused on ensuring safe and reliable tests performed during transport. It ensures optimal pa- transport from the scene of an emergency to the nearest tient treatment, both during transport and upon arrival at hospital. Today, it offers high-quality prehospital care by the hospital. specialized professionals and is tightly integrated with other healthcare services. Mobilizing citizens has tripled survival rates In many emergency situations, time is of critical impor- This white paper presents some of the key features of tance. For a citizen suffering from cardiac arrest, for in- Denmark’s EMS system, focusing on the transformation it stance, survival chances will often depend on the actions has undergone in recent decades. It also describes some of bystanders before medical staff arrives. This fact has of the considerations and concerns that have shaped triggered a nationwide effort to encourage and educate these changes – and remain in focus as the EMS contin- citizens to handle emergencies. ues to evolve. In 2005, Denmark launched a national program to train cit- Treatment begins in the ambulance izens in performing Cardiopulmonary Resuscitation (CPR). Today, emergency medical services provide much more At the same time, about 19,000 Automated External De- than a means of transport and basic treatment of symp- fibrillators (AED) – one for every 300 citizens – have been toms. Technological advances and enhanced skill levels of installed and registered, making them accessible to both emergency staff allow for highly specialized treatment to healthcare professionals and citizens. begin at the scene of an emergency and continue during transport. The results have been remarkable. Since 2001, citizen participation in CPR has increased from 19 percent to 67 per- Emergency Medical Technicians (EMTs) and paramedics cent, and survival rates have tripled. will often provide help, which would traditionally be considered ‘hospital treatment’. Data analysis, telemedicine, Developing EMS for the future and point-of-care technologies have become an integrated This white paper describes some of the innovative solu- part of ambulance treatment. tions that the Danish healthcare sector has employed to increase the chance of successful outcomes in emergency Ambulance services are also supplemented by a num- situations. ber of other specialized emergency units. In the case of a life-threatening emergency, a physician-staffed Mobile But the EMS is constantly exploring new ways to further Critical Care Unit (MCCU) will usually be dispatched. For improve emergency care — in close collaboration with hos- time-critical emergencies the dispatch center can deploy pitals, municipalities and private companies as well as indi- the Helicopter Emergency Medical Services (HEMS). Other vidual patients, their families, and the community. units are specialized in handling emergencies that involve infants, psychiatric patients or socially vulnerable citizens.

At the same time, digital technologies have made it possible to improve communication immensely, supporting seamless coordination and cooperation between ambulance staff, emergency departments, and hospital units.

3 SUSTAINABLE HOSPITALS Emergency Medical Services © Flemming Leitorp

“All citizens in Denmark must feel secure and have access to the help they need in the event of an accident or acute illness. In many cases, it is a matter of life and death. This is why we maintain a high level of specialized prehospital care in emergency medical services (EMS).”

Ellen Trane Nørby MINISTER FOR HEALTH

Foreword

“All citizens in Denmark must plays a crucial role. A national effort to train equal access to emergency medical services feel secure and have access to and encourage citizens to perform CPR has – irrespective of where you live, who you are, the help they need in the event increased the chances of surviving a cardiac or what you earn. But even though Denmark of an accident or acute illness. arrest immensely. is a relatively small country and new technol- In many cases, it is a matter of In Denmark, the distance between the scene of ogies enable us to improve prehospital care life and death. This is why we maintain a an emergency and the nearest hospital is in our ambulances, it remains a challenge to high level of specialized prehospital care not as important as it once was. Today, treat- ensure emergency services in remote areas in emergency medical services (EMS).” ment is initiated as soon as the emergency far from hospitals. Ellen Trane Nørby, Minister for Health staff arrives at the scene, by ambulance or In recent years, we have improved the EMS in helicopter, and continues on the way to the a number of ways. Initiatives such as volun- The sooner treatment is initiated, the better nearest emergency ward or specialized hos- teer first responders, heart runners and a na- the chances of survival. Be it a myocardial pital department. Our innovative prehospital tionwide network of publically accessible de- infarct, a stroke or a serious accident, time is patient record system enables prehospital fibrillators have created remarkable results. a crucial factor. This is why our ambulances data to be transferred automatically to the For instance, Denmark has doubled survival are considered a crucial part of a compre- hospital. This allows our doctors and nurses rates for out-of-hospital cardiac arrest dur- hensive emergency effort outside the hospi- to prepare for the patient’s continued treat- ing the last two decades. tal. Staffed with paramedics and emergency ment even before the ambulance arrives at But our efforts to improve the EMS do not medical technicians who are trained to deal the hospital. stop here. In 2018, Denmark has already with life-threatening illness and injuries, am- Data analysis, telemedicine, and point-of- prioritized resources for a fourth emergen- bulances are the first to arrive on the scene. care technologies have become an integrat- cy medical helicopter and introduced emer- Along with well-equipped emergency vehi- ed part of prehospital care, often co-devel- gency medicine as a new specialty in the cles and helicopter emergency medical ser- oped with private partners. Denmark is also education of doctors. Going forward, we will vices, they provide crucial help. a front-runner when it comes to diagnosing continue to introduce new initiatives that More than 9 out of 10 ambulances arrive heart conditions in the ambulance. This al- strengthen prehospital care. within 15 minutes, which is fast – but not lows patients with suspected acute coronary always fast enough. If someone suffers a syndrome to be transported directly to a Ellen Trane Nørby cardiac arrest, every minute counts. This is specialized heart center. why Cardiopulmonary Resuscitation (CPR) A core value in Danish healthcare is free and

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6 It takes a 3 Executive system to save Index summary 4 Foreword lives

8 Cooperation 9 Bringing the hospital and coordination to the patient

10 Helicopters ensure equal 11 1813: A gateway to urgent access to healthcare medical help

12 Artificial intelligence helps medical dispatchers identify 13 The first emergency room is cardiac arrest patients in the ambulance

14 Electronic patient records in Danish am- 15 Heart patients are diag- bulances nosed in the ambulance

16 Ensuring optimal care 17 Big data enables quick for stroke patients emergency response

18 Integrated solution 19 Mobilizing citizens has tripled improves emergency care survival rates

20 An AED in every town and every community 21 Volunteers save lives

22 The future of Emergency Med- 23 About ical Services in Denmark Healthcare DENMARK

5 SUSTAINABLE HOSPITALS Emergency Medical Services

It takes a system to save lives

Emergencies require fast and res- clinical hub, which identifies, prioritizes and as possible. The bystander is in contact with olute action from both citizens dispatches the right resources. the EMS dispatch center the whole time. The and healthcare professionals. But EMS dispatches an emergency physician and the success of these efforts ulti- It ensures effective coordination and seam- a paramedic while guiding the bystander until mately depends on an effective less cooperation between the dispatch center, the emergency team arrives. emergency management system. Over the ambulance services, and the emergency the past few decades, Denmark has built a department. When the physician and the paramedic arrive, healthcare system where Emergency Med- they provide advanced life support and rush ical Services play an important role. The chain of survival the patient to the emergency department for Critical emergencies trigger a ‘chain of surviv- treatment. Denmark’s Emergency Medical Services al’, which includes a number of time-sensitive, (EMS) have changed substantially during the coordinated steps that need to be taken to Everyone in this ‘chain of survival’ can take last two decades. Traditionally, the EMS has establish the best possible chance of suc- pride in saving the man’s life. But it was focused on safe and comfortable transport cess. If even one link is weak or missing, the made possible by a well-coordinated system to the nearest hospital. Today, the EMS pro- chances of survival are significantly reduced. that supports life-saving actions and links the vides highly specialized prehospital care and Therefore, Denmark uses new, innovative, po- individual efforts of the multiple people and is increasingly integrated with other health- tentially life-saving approaches to save critical departments involved. care services. time in emergencies. Building on Denmark’s strengths The Emergency Medical Dispatch Center is Picture a man collapsing in central Copenha- The transformation of the EMS in Denmark the ‘gatekeeper’ to emergency care, providing gen due to cardiac arrest. A bystander, who reflects a general shift in healthcare delivery citizens with instructions to begin care, such is also a ‘heart runner’, is alerted through a nationwide – namely the concentration of as telephone-assisted CPR, until healthcare smartphone application and rushes to the medical care at fewer, highly specialized hos- professionals arrive. It is also an important man to begin resuscitation efforts as quickly pitals and emergency departments.

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Denmark and the Danish healthcare system • Denmark has a population of about 5.8 million people and an area of 43,094 km2. • The Danish healthcare system is a public system, based on the principle of equal and free access to healthcare for all citizens. The majority of the Danish healthcare services are financed by taxes.

The Danish healthcare system operates on three levels: • National level. The Parliament and the Government set the regulatory framework. • Regional level. Five regions are responsible for operat- ing the hospitals in their respective geographies. • Local level. 98 municipalities are responsible for population health, prevention initiatives, rehabilitation, home care, and elderly care. This new hospital landscape has paved the way for a new emergency structure, which reduces the number of emergen- Danish Emergency Medical Services cy departments from 40 to 21. The new joint emergency de- The Danish prehospital services encompass a number of partments will ensure that all citizens get the same high-qual- cross-disciplinary emergency functions, collectively re- ity treatment. ferred to as the EMS. These functions include: • Emergency Medical Dispatch Centers (112) Due to demographic changes and the increasing prevalence • Dispatch and control centers for ambulances and Heli- of lifestyle diseases and chronic conditions, Denmark has had copter Emergency Medical Services (HEMS) an increased focus on data-driven and evidence-based solu- • Mobile critical care units (MCCU) tions that enhance the quality of prehospital treatment. • Medical call centers for referral and admission to emergency departments, admission to hospitals, and Denmark has the advantage of being a highly digitalized medical advice services for all citizens. country. Public institutions are generally fast movers when it • Out-of-hours primary care services, including home vis- comes to exploring new digital possibilities, and citizens tend its by physicians. to embrace digital solutions and integrate them effortlessly • Prehospital psychiatric care units. into their everyday lives.

In 2017, there were: The unique Danish Personal Identification Number, which was • 1.7 million acute cases in Danish hospitals introduced in 1968, further supports the ambitious approach • more than 3 million calls to regional medical helplines to digitalizing the EMS. • over 700,000 ambulance and hospitalized transports

A uniform prehospital system across the country ensures that experience and data gathered over many years are drawn upon to determine the best possible solution for each patient.

7 SUSTAINABLE HOSPITALS Emergency Medical Services

The chain of survival.

Cooperation and coordination

To handle emergencies success- Elvira’s life was saved by a highly efficient fully, the EMS must ensure a swift, EMS system where emergency medical tech- efficient and coordinated re- nicians and paramedics collaborate closely sponse. with critical care physicians in a highly coordinated effort. One day, 1-year old Elvira choked on a piece of apple; she could not breathe and had a In serious or life-threatening emergencies sudden cardiac arrest. such as this, a physician-staffed Mobile Criti- cal Care Unit (MCCU) will often be dispatched Luckily, she was with her nanny, Lærke, a simultaneously with the ambulance, meeting brave girl in her twenties, who immediately it at the patient’s location. Close cooperation realized that this was an emergency and di- and interaction is essential: The ambulance aled 112. At the medical dispatch center, a staff must reach the patient quickly and ini- nurse instructed Lærke to perform CPR, guid- tiate the proper treatment or tests until the ing her continually over the phone until the MCCU arrives. arrival of the ambulance and a critical-care physician. The emergency staff continued Today, Elvira is a fun-loving 8-year old girl with CPR on the way to the hospital, where a team a passion for stuffed animals. of specialists, who had already been alerted in advance, took over Elvira’s treatment.

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“...They can initiate high-quality intensive care therapy as well as minor, but often life-saving surgical procedures on location.”

Bringing the hospital to the patient

The Danish ambulance service is In serious or life-threatening emergencies, a • A psychiatrist-staffed MCCU responds to supplemented by a Mobile Critical Mobile Critical Care Unit (MCCU) staffed with mental health emergencies. The consult- Care Unit and a number of other physicians and/or paramedics is dispatched ant psychiatrist provides qualified emer- emergency units, providing urgent simultaneously with the ambulance, meeting gency mental healthcare on the scene or care for infants, psychiatric pa- it at the patient’s location. The MCCU also by phone and ensures that citizens with tients and other groups who need highly functions as a transfer-and-retrieval service serious mental health issues get the ex- specialized treatment. for critically ill patients, who need to be trans- pert emergency help they need ‘out-of- ferred between hospitals. hours’. Ambulances are the backbone of Denmark’s • The Sociolance is staffed with a social EMS system. They respond to a variety of worker and a paramedic. The unit operates calls, many of which are serious or life-threat- “Our specialized medical in the city center, helping homeless, social- ening. They provide urgent care and transport teams bring the hospital to ly marginalized, or otherwise vulnerable cit- for the sick and injured until they reach the izens in need of urgent social care. hospital. More than 9 out of 10 ambulances the patient.” • The Babylance is a specialized neonatal re- arrive within 15 minutes. trieval unit staffed with a paramedic and a neonatal doctor-nurse retrieval team. Its Ambulances are staffed with paramedics “Our specialized medical teams bring the design allows the baby and the family to and emergency medical technicians trained hospital to the patient. They can initiate be transported safely in the same vehicle. to deal with life-threatening illnesses and in- high-quality intensive care therapy as well as • In mass casualty incidents, EMS Copen- juries. Prehospital physicians can perform in- minor, but often life-saving surgical proce- hagen can deploy two Mobile Treatment vasive procedures, which may be required in dures on location.” Areas, providing a safe environment for serious medical emergencies. - Dr. Peter Anthony Berlac, Medical Director up to 80 casualties at a time and optimal at Emergency Medical Services Copenhagen working conditions for front-line staff. The Several specialized and innovative rapid re- units also provide excellent medical facili- sponse units supplement the ambulance ser- In larger urban areas, the MCCU is supple- ties for large-scale planned events such as vice, providing medical expertise at the scene mented by a number of additional specialized festivals or marathons. of the emergency. units:

9 SUSTAINABLE HOSPITALS Emergency Medical Services

Helicopters ensure equal access to healthcare

Helicopter Emergency Medical Services enable equal access to healthcare across the country and rapid transport to specialized care facilities.

Quick visitation and transportation is a key element in a new This ensures equal access to healthcare in remote and/or sparsely emergency response system with fewer emergency departments. populated parts of the country, where the nearest hospital for spe- The Helicopter Emergency Medical Services (HEMS) have become an cialized care might be far away. important part of Denmark’s emergency care for critically-ill patients, enabling equal access to high-quality treatment for all citizens. ”Helicopters ensure access to specialized The Emergency Dispatch Centers will send helicopters along with am- treatment, no matter where you live, and bulances and MCCUs in time-critical emergencies, i.e. when urgent thereby support equality in healthcare.” medical care is needed on location, or when flying the patient to a highly specialized hospital can save critical time. For instance, if a citizen in Western Denmark collapses from acute coronary syndrome and needs treatment in one of the large university hospitals, a helicopter can make a lifesaving difference.

Facts ”It is important, that patients in all parts of Denmark can receive • Denmark’s five regions share four helicopters under a joint immediate care in time-critical cases such as a stroke or acute coro- emergency management system. nary syndrome. Helicopters ensure access to specialized treatment, • In 2017, the helicopters were dispatched 3,658 times. no matter where you live, and thereby support equality in healthcare.” • The HEMS operates day and night, all year round. – Svend Hartling, Chairman of the National Emergency Medical Heli- copter Organization.

10 INNOVATING BETTER LIFE 1813: A gateway to urgent medical help

In the Capital Region of Denmark, the patient’s need for help and determine the proper course of action. If a patient’s situation the Medical Helpline (1813) and Facts becomes more severe (or improves), the level the EMS (112) collaborate in a fully • The Medical Helpline is part of the of help can be adjusted in order to prioritize digitalized dispatch center. Doc- public health system and is free of resources in the best possible way. tors and nurses help citizens who charge. have become acutely ill or suffered an ac- • It provides acute help when GPs cident. “The Medical Helpline 1813 are unavailable; from 4 p.m. until 8 a.m., during weekends and public A father dials 1813 because his child has a provides important and holidays. high fever. At the same time, a husband calls accessible help to citizens • It covers 1.8 million citizens in the the emergency medical service 112 because Capital Region of Denmark, includ- his wife has been in an accident and is not who feel ill or have minor ing the remote island of Bornholm, breathing. injuries.” and takes 1 million calls per year. • From 2019, a new national emer- Both calls are answered by doctors, nurses, gency number (113) will include the “The Medical Helpline 1813 provides impor- and paramedics at the EMS Copenhagen. The services of the Medical Helpline. nurses receive special training in order to en- tant and accessible help to citizens who feel ill sure a high level of expertise and skills when or have minor injuries. Healthcare profession- answering emergency calls. Since 2014, when als will find the right response; sending an am- the Medical Helpline was set up, healthcare bulance, referring to a doctor or sometimes professionals have been collaborating and co- just recommending that the patient stay at ordinating the triage: The Medical Helpline and home and get some rest.” the Emergency Medical Service can direct calls – Freddy Lippert, CEO at the Emergency Med- from one unit to another in order to clarify ical Services Copenhagen.

11 SUSTAINABLE HOSPITALS Emergency Medical Services

Artificial intelligence helps medical dispatchers identify cardiac arrest patients

In Copenhagen, the EMS has ap- the severity of the situation. One time out on artificial intelligence is trained to iden- plied artificial intelligence to rec- of three, the bystander has not identified tify cardiac arrest from the ongoing calls ognize cardiac arrest and support the cardiac arrest at the time of the call to to 112. By analyzing the call, ‘listening’ for real-time decision making at the the emergency medical services. Bystanders patterns in the dialogue referring to cardiac dispatch center. often mistake cardiac arrest for other condi- arrest, it can alert the medical dispatcher tions or misinterpret the patient’s condition who is handling the call. When analyzing When a person collapses from cardiac ar- and breathing. the call in real-time, the solution compares rest, it is critical to quickly identify and di- the ongoing call to the history of calls and agnose the cardiac arrest in order to provide In Copenhagen, the EMS has taken a unique calculates the probability of a cardiac ar- the correct emergency service. However, it approach to increase the recognition of rest. can be difficult for a bystander to identify cardiac arrests. An innovative device based Currently, the artificial intelligence solution can correctly identify approximately 85 percent of cardiac arrests – compared to ap- Facts proximately 75 percent recognized by med- • Artificial Intelligence can support the decision-making process for the dispatchers. ical dispatchers. This translates into 150 • The solution has been trained on more than 100,000 calls. more patients now being recognized prior to • A randomized clinical trial using artificial intelligence began in September 2018. the ambulance arriving. • Artificial intelligence can also play an important role as a decision support tool for medical dispatchers, in other time-critical conditions such as a stroke, acute myo- The artificial intelligence solution has been cardial infarct or sepsis. developed in a cooperation between EMS Copenhagen and the Danish company, Corti.

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The first emergency room is in the ambulance

In the past, ambulances were ment as soon as the ambulance arrives at medicine solutions have made it easier to mainly regarded as emergency the hospital. initiate correct medical treatment as soon transport to a hospital. Today, they as possible. Emergency Medical Technicians are considered the first part of a (EMTs) and paramedics will often be able to comprehensive emergency effort “Data analysis, telemedicine, provide help, which would traditionally be outside the hospital. and point-of-care technolo- considered ‘hospital treatment’.

In Denmark, the distance between the gies have become an inte- Today, ambulance staff provides much scene of an emergency and the nearest grated part of ambulance more than a means of transport and ba- hospital is not as important as it once was. sic treatment of symptoms. Data analysis, Highly specialized ambulance staff, ade- treatment” telemedicine, and point-of-care technol- quately equipped emergency vehicles and ogies have become an integrated part of the availability of helicopter emergency The visitation at the dispatch center is fol- ambulance treatment, making EMS profes- medical services mean that treatment will lowed by a healthcare evaluation and visita- sionals ‘the extended arm’ of the hospital. often begin at the scene and continue dur- tion in the patient’s own home in order for Screening and diagnostics can take place ing transportation. the patient to be either fully treated or trans- in the ambulance itself, which is signifi- ported to the right treatment facility as early cant as it allows the paramedics to trans- At the same time, technological advances as possible. port the patient directly to a specialized have improved communication between am- hospital. bulances and hospitals. This enables doctors The systematic use of protocols, increased and nurses to continue appropriate treat- skill levels of ambulance staff and new tele-

13 SUSTAINABLE HOSPITALS Emergency Medical Services

Electronic patient records in Danish ambulances

All ambulances in Denmark use All ambulances are equipped with a touch – Peter Larsen, CEO, MSc, Emergency prehospital records, collecting screen computer, and patient information is Medical Services, North Denmark Region. and storing data in one central transmitted between the ambulance and the database. Denmark’s unique emergency department through the mobile A public-private innovation partnership collection of prehospital data has network. The amPHI solution stems from a public- improved cooperation and coordination private partnership between the North between ambulances and hospitals. Pioneer work in the North Denmark Region Denmark Region and a small group of private has created the basis for a comprehensive Danish companies. Judex, an IT company In serious emergencies, quick initial national solution across all formal, publicly specializing in healthcare, has delivered the treatment at the scene is crucial. But funded prehospital systems in Denmark’s software and the technical setup, while the patient’s prospects of recovering, or five regions. Falck Ambulance provided knowledge and even surviving, also rely on the quality and experience on optimizing interaction and accuracy of the prehospital documentation The prehospital record gives a unique registration in the ambulances. The North and information given to the emergency opportunity to collect data for prehospital Denmark Region is responsible for the server department when the patient is admitted. research. It is now possible to follow a group setup and the workflow in the emergency of patients with specific symptoms, from department. Denmark has an innovative prehospital the first call to 112 until the ambulance record system, developed by amPHI arrives at the address. The data includes The solution is being continuously developed Systems, which automatically transfers symptoms, treatment provided by the EMTs, and improved to ensure integration with crucial prehospital data directly to the and vital indicators registered on arrival at other systems, point-of-care devices, and hospital’s electronic records. This enables the hospital. logistics systems and to optimize the doctors and nurses to prepare for the transfer of live data. patient’s continued treatment even before “The national prehospital record system has the ambulance arrives at the hospital. been and still is a unifying factor in the Danish Similarly, the EMS system has access to EMS system and may today be regarded as the patient’s medical history to ensure the a unique tool for ongoing improvements optimal treatment of the patient on site to EMS, knowledge sharing, research, and in the ambulance. supervision and training of paramedics.”

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Heart patients are diagnosed in the ambulance

Denmark is a front-runner in the In the case of high ACS risk, the patient will means that patients are diagnosed faster, treatment of acute coronary syn- be transported directly to a specialized heart and treatment such as percutaneous cor- drome (ACS). As part of a national center. onary intervention can be performed at an research project, patients with early stage. On average, ACS patients diag- suspected ACS are transported di- ”...patients are diagnosed nosed in the ambulance are discharged two rectly to a specialized heart center instead days earlier from the hospital.” of the local hospital. faster, and treatment such - Christian Juhl Terkelsen, MD, DmSc, PhD, as percutaneous coronary Associate Professor, Aarhus University Hos- If an emergency patient complains about pital, Department of Cardiology, Central Den- chest pains, ambulance staff will prepare intervention can be per- mark Region. an electrocardiogram (ECG) and perform a formed at an early stage. blood test in order to detect possible acute The procedure is an example of a ‘Point of coronary syndrome at an early stage. On average, ACS patients Care Test’ introduced to assure that the pa- diagnosed in the ambulance tient is given the appropriate treatment as As the first country in the world, Denmark early as possible. has extensively researched the use of devic- are discharged two days es that can measure the levels of cardiac bi- earlier from the hospital.” Based on favorable results in clinical trials, omarkers from a blood sample. While major it is expected to be introduced in all Danish coronary infarctions will often be revealed by regions. an ECG, this is not always the case with mi- nor ones. But elevated levels of cardiac bio- ”With the combination of blood tests and markers will often indicate a high probability ECG, we detect far more instances of in- of ACS. creased ACS risk in the ambulance. This

15 SUSTAINABLE HOSPITALS Emergency Medical Services

Ensuring optimal care for stroke patients

The Danish healthcare system fo- tion and treatment. This will save the life and ”With a joint national tool for cuses on prompt and systematic mobility of many patients.” screening of stroke patients in the - Per Sabro Nielsen, Ph.D, MPM, Medical Di- screening of stroke, we can ambulance to ensure that they re- rector, Emergency Medical Services, Central ensure fast and correct vis- ceive qualified care immediately. Denmark Region. itation and treatment. This Rapid diagnosis of stroke patients is often Correct visitation is critical will save the life and mobility critical to their survival and future mobility. All Danish regions have implemented new Detecting the location of a blood clot and as- screening tools and tests in the ambulances of many patients.” sessing the severity of the patient’s condition to support paramedics in the early detec- will allow for subsequent visitation to the rel- tion of stroke symptoms, enabling them to evant specialized hospital department. bring the patient to the appropriate treatment facility. Therefore, the five Danish Regions and the Danish Health Authority have initiated a natio The paramedics will report the results to nal effort to improve the quality of care for a neurologist at the hospital. If the results stroke patients. In close collaboration with pro- indicate a minor stroke, the patient will fessional experts, they have developed a joint usually be transported to the local hospital national model for screening in ambulances. for medical treatment. In the case of a major stroke, the patient will immediately be ”With a joint national tool for screening of transported to a highly specialized depart- stroke, we can ensure fast and correct visita- ment for surgery.

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Big data enables quick emergency response

Time is crucial when technical to a reduction in the average response time “We use big data to make optimal use of dispatchers coordinate emergen- – the elapsed time from an ambulance is resources. To do so, we need a tool that can cy calls across an entire region. provide an overview of our operation in real A business intelligence solution “We use big data to make time. Such a tool has been successfully de- provides a real-time overview of veloped in close collaboration with the com- the resources at hand, ensuring that help optimal use of resources. pany KMD.” arrives as quickly as possible. To do so, we need a tool that - Kim Ahlers, Head of the Emergency Dis- patch Center, the Region of Southern Den- The Danish healthcare sector continuously can provide an overview of mark. produces huge amounts of data. By pro- our operation in real time. cessing and analyzing data from ambulanc- The solution can also be used for a number es, emergency dispatch centers and hos- Such a tool has been suc- of other optimization purposes: ensuring pitals, an innovative business intelligence cessfully developed in close the best placement of emergency stations, solution can optimize planning and improve adjusting the number of ambulances, and prioritization. This enables the dispatchers to collaboration with the com- setting relevant performance targets for get a real-time overview in their daily work- pany KMD.” emergency personnel. In this way, it not only flow and allocate their resources accordingly enhances coordination and assures data to ensure a quick response in an emergency quality in real time, but also supports long- situation. requested until it reaches its destination – term decision-making. which is a vital performance indicator for As such, the solution has helped improve the dispatchers who coordinate emergency the quality of data and thereby contributed requests.

17 SUSTAINABLE HOSPITALS Emergency Medical Services

Integrated solution improves emergency care

All Danish regions have imple- psychiatrists out of hours; hospital admis- an ambulance or any other emergency re- mented a computer aided dispatch sions; and scheduling appointments with sponse. (CAD) solution developed in close emergency departments, emergency den- public-private partnerships. In the tists or general practitioners. If the patient needs to visit an emergency Capital Region, an integrated digi- department, she can check for available tal platform allows EMS staff to seamlessly Besides the emergency number (112), Co- times at emergency departments nearby manage a wide variety of services. penhagen citizens can call a medical hotline and schedule an appointment immediately. (1813) at all times, if they need medical help This dramatically reduces waiting times and EMS Copenhagen has integrated all outpa- or advice. improves overall patient care. tient services into one single computer aided dispatch (CAD) solution developed jointly by Both numbers are handled by the EMS Co- Referral or discharge notes are automatically EMS Copenhagen and the Danish company penhagen call centre and use the same inte- collected from the patient charter and sent Logis Solutions. grated IT system. to the appropriate recipient, ensuring that no information is lost in transition between It includes workflows that allow call takers If a nurse takes an 1813 call, and the pa- healthcare departments. In cases of emer- and dispatchers to seamlessly manage a tient’s condition deteriorates while on the gency response, all relevant information is wide range of services: Traditional emergen- phone, a simple click of a button will al- automatically sent in real time to a mobile cy and non-emergency dispatching; alloca- low her to switch from the hotline to the unit in the ambulance. tion of nurses, paramedics, physicians or emergency system and quickly arrange for

18 INNOVATING BETTER LIFE

“Denmark has become a prime example of implementing best resuscitation practice in Europe and has achieved a remarkable tripling of survival rates from Out-of-Hos- pital Cardiac Arrests over the past ten years.”

Mobilizing citizens has tripled survival rates

If a citizen suffers a cardiac arrest ily available in public places. Since 2006, in Denmark today, he is three times more than 19,000 AEDs have been installed more likely to survive than he would throughout the community. have been a decade ago. This is due to the national effort to educate As a result, the number of incidents, in which and encourage bystanders to perform Car- bystanders perform CPR, increased from 19 diopulmonary Resuscitation (CPR). percent to 67 percent.

Every year, 4,000 people suffer Out of Hos- In addition to the improved survival rates, the pital Cardiac Arrests (OHCA) in Denmark. percentage of survivors returning to work Since 2001, survival rates have tripled from has increased significantly. 76.6 percent of 4 percent to 12 percent. This extraordinary 30-day survivors (who were employed before improvement is the result of a concentrated the incident), returned to work. effort from many parties. This reflects that neurological outcomes “Denmark has become a prime example of have generally become more favorable, due implementing best resuscitation practice in to a more efficient EMS system. Europe and has achieved a remarkable tripling of survival rates from Out-of-Hospital Acknowledging that all systems can perform Cardiac Arrests over the past ten years.” smarter and better, Denmark’s five regions – Freddy Lippert, CEO at the Emergency have taken action to implement the Resusci- Medical Services Copenhagen. tation Academy.

In 2005, Denmark launched a national pro- Denmark is one of the founding members of gram aimed at teaching its citizens to per- the Global Resuscitation Alliance. The alliance form CPR. It included mandatory training for seeks to advance resuscitation by accelerat- drivers and elementary school students, the ing community implementation of effective distribution of instructional training kits, a programs. These programs build on the telephone guidance service for bystanders, Resuscitation Academy model and follow a and a comprehensive effort to make Auto- quality improvement strategy of measuring mated External Defibrillators (AED) read- and improving.

19 SUSTAINABLE HOSPITALS Emergency Medical Services

An AED in every town and every community

The Danish AED Network has Therefore, TrygFonden saw a great potential made thousands of AEDs acces- in activating citizens to use AEDs.” Facts sible to EMS professionals and - Grethe Thomas, Project Director at the Dan- • The AED Network is maintained by citizens and succeeded in raising ish foundation TrygFonden. the non-profit foundation TrygFond- awareness of CPR. en. “In the case of a cardiac • Owners of AED equipment can reg- The Danish AED Network comprises sev- ister it on the website hjertestarter. eral thousand AEDs, which are available to arrest, the chances of dk. This will make it visible on an everyone; citizens as well as the EMS. All survival increase by up to 50 online map and potentially available AED owners – private citizens, corporations to citizens as well as EMS profes- and public institutions – are encouraged to percent if an AED is used sionals. register their devices with the AED Network, before ambulance arrival. • As of September 2018, approxi- making them visible on an online map. mately 19,000 AEDs had been reg- Therefore, TrygFonden saw a istered across the nation – one for In the event of a suspected cardiac arrest, great potential in activating every 300 citizens. citizens or EMS professionals can access the • Since the implementation of the website hjertestarter.dk to locate the near- citizens to use AEDs.” AED Network, the reported instanc- est AED. es of bystanders performing de- fibrillation has increased from 2,1 All emergency dispatch centers have inte- The map is updated several times a day, percent in 2008 to 13,4 percent in grated their systems with the AED Network. so dispatchers will always be able to guide 2016. bystanders directly to the nearest available “In the case of a cardiac arrest, the chanc- AED. When an AED is in use, the call center es of survival increase by up to 50 percent will automatically receive a message to de- if an AED is used before ambulance arrival. activate it on the network’s website.

20 INNOVATING BETTER LIFE

“In recent years, Danish citizens have provided invaluable assistance to the emergency services, especially in areas with higher ambulance response times. Increased citizen participation makes it realistic to further improve rates of survival from sudden illness and cardiac arrest.”

Volunteers save lives

Denmark uses innovative, poten- • In the Capital Region of Denmark and the the three first responders closest to the tially life-saving approaches to mo- Central Denmark Region, the dispatch event automatically receive a notification bilize volunteers. centers now have the option of activating on their mobile phone. ‘heart runners’ – volunteer citizens trained The chances of survival after an in resuscitation – through a smartphone ap- At all times, the EMS knows which resourc- out-of-hospital cardiac arrest depend heavi- plication. The application is integrated with es are on their way and will be able to guide ly on early CPR and/or the use of an AED. the Danish AED Network. If the EMS staff and instruct emergency professionals, volun- Time is critical. Every minute matters, and suspect a cardiac arrest when they take teers, and bystanders accordingly. bystanders’ actions before the arrival of EMS an emergency call, a geolocation system is personnel could often mean the difference used to automatically locate and alert near- between life and death. by heart runners, directing them to the closest publicly accessible AED and the scene of This fact has prompted the EMS to explore the incident as quickly as possible. new ways of engaging citizens in handling cardiac arrests and other time-critical emer- • In the Region of Southern Denmark, the gencies and offering critical first aid and overall emergency response system in- basic life support until professional medical cludes a volunteer network of ‘first re- care is available. sponders’ – volunteers trained in first aid and basic life support, including the use of “In recent years, Danish citizens have provid- AEDs. When an ambulance is dispatched, ed invaluable assistance to the emergency services, especially in areas with higher ambulance response times. Increased citizen participation makes it realistic to further im- Facts • The heart runner concept was implemented in the Capital Region of Denmark in 2017. prove rates of survival from sudden illness It was developed in collaboration with the non-profit foundation, TrygFonden, cardiac and cardiac arrest.” arrest researchers, and the regional EMS unit. In the first year, 25,000 citizens regis- - Benny Jørgensen, CEO at the Emergency tered as heart runners, and 6,500 of them have been involved in over 800 resuscita- Medical Services, Region Zealand. tion attempts. The Central Denmark Region implemented the concept in 2018 and within the first two months, 10,000 citizens registered as heart runners. All Danish regions have integrated citizen • The first responders concept builds on an application-based technology provided by participation with the general emergency re- the Danish company, First AED. It is an integrated part of the dispatch system in the sponse system. Region of Southern Denmark. First responders are deployed in cases of out-of-hospital cardiac arrests and other serious emergencies. The two initiatives below illustrate some of the innovative and life-saving approaches.

21 SUSTAINABLE HOSPITALS Emergency Medical Services

The future of Emergency Medical Services in Denmark

Emergency medical services play an important part in meeting global healthcare challenges. Denmark has fostered a number of new initiatives to improve future emergency care.

Across the world, demographic changes and increasing expectations from citizens pose a great challenge to healthcare providers.

Emergency medical services can play an important part in meeting this challenge.

It is not just a matter of deploying more ambulances or reducing response times. It is about creating innovative solutions and integrating new technologies to ensure appropriate early treatment and to facilitate the best pos- This white paper has presented some of the innovative sible collaboration and coordination between emergency solutions already used to ensure highly specialized pre- wards, specialized hospital departments, municipalities, hospital care and to increase the chance of successful fire and rescue services, community volunteers, and local outcomes in emergency situations. But this is just the healthcare providers. beginning. Denmark continues to explore new ways to improve emergency care. Denmark strives to be a frontrunner in the transition of the EMS along these lines. This task requires close collaboration with hospitals, municipalities and private companies. However, individual The EMS is usually the initial, if not the only, point of con- patients, their families, and the community remain the tact for patients with acute illness and injuries. As such, most important partners in this transition. the EMS is not only responsible for initiating care, but also operates as a gatekeeper to the entire healthcare system. To learn more about the Emergency Medical Services in Denmark, feel free to contact Healthcare DENMARK. If The transition is supported by a strong tradition of data- you want to visit Denmark to study its innovative solu- driven research and evidence-based care in the Danish tions in detail, you can request a delegation visit through healthcare sector. the Healthcare DENMARK website.

Facts The EMS is constantly exploring new ways to further improve emergency care. Current initiatives and research projects include: • The application of artificial intelligence to support decision making in emergency calls and emergency care. • Video consultations with citizens to support early diagnostics and treatment at home. • Digital assessment and triage supported by app- or internet-based communication with citizens. • Utilizing data and new technology to promote the use of AEDs (Automated External Defibrillators) in events of cardiac arrest. • Point-of-care tests in prehospital settings, allowing for early diagnostics and treatment. • The use of paramedic practitioners or community paramedics to provide patient care in local communities. • Exploring the potential of drones (for example, live-stream video transmission to dispatch centers) in accidents, search and rescue operations and other major incidents.

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About Healthcare DENMARK

Healthcare DENMARK is the inter- national gateway to Danish healthcare expertise and innovation. Our aim as a non-profit public-private partnership is to internationally benchmark Danish best practices within healthcare.

The goal of Healthcare DENMARK is not to HRH Crown Princess Mary of Denmark patron of Healthcare DENMARK sell or promote any specific products or solutions, but to communicate you with local accommodation and transpor- the strong- tation. holds of Danish healthcare. We Healthcare DENMARK has a national and po- do this by at- litical mandate to provide this service to pol- tracting health iticians, relevant top and management level politicians, de- professionals, and journalists working with cision-makers, healthcare. and journalists to experience Backing this public-private initiative is a part- Danish health- ner group of both public and private key actors Hans Erik Henriksen care solutions within Danish healthcare, including the Minis- Chief Executive Officer in practice and try of Health, the Ministry of Foreign Affairs meet the peo- of Denmark, the Ministry of Industry, Business ple behind. Our network is an extensive pool & Financial Affairs, Danish Regions, Region of public sector, private companies, and other of Southern Denmark, the Confederation of actors in the area of healthcare – all dedicated Danish Industry, the Confederation of Danish to providing excellent and efficient healthcare Enterprise, Falck, KMD, Systematic, OpenTele- as well as sharing best practices across bor- Health, Intelligent Systems, Danish Export As- ders and professions. sociation, Lyngsoe Systems, Wavecare, Dan- ish.Care, and PDC. ’’In Denmark our focus on putting the patient first – combined with efforts to improve ef- Her Royal Highness Mary, Crown Princess of ficiency and quality – has resulted in a wide Denmark is patron of Healthcare DENMARK. array of innovative solutions. I sincerely believe Danish solutions and expertise can have a pos- Visit www.healthcaredenmark.dk to learn more itive impact on global health.” - Her Royal High- about some of the world’s best and most in- ness Crown Princess Mary of Denmark novative healthcare providers and com- If you would like to learn more about our panies or to request Stay updated with world-renowned healthcare, we can assist you meetings with the our newsletter Visit our website with tailoring a visiting program, setting up stakeholders who healthcaredenmark.dk meetings, and arranging access to otherwise are future-proofing and sign up! off-limits areas and people within both the healthcare sectors public and private sectors, as well as assist around the world.

23 Healthcare DENMARK SUSTAINABLE HOSPITALS Forskerparken 10H Phone: +45 23 84 00 56 INNOVATING BETTER LIFE Emergency Medical Services DK-5230 Odense M [email protected]