State of emergency medicine in Spain

Spain has more than 3,000 PCCs, which are run by family doctors (general practitioners) and pediatricians. Some PCCs also include other specialties such as gynecology and orthopedic surgery. On average, there is 1 PCC for every 15,000 to 20,000 inhabitants, and every family doctor is in charge of 1,500 to 2,000 citizens, although less populated zones tend to have lower ratios. Doctors spend part of their duty time in providing emergency care to their own patients. They are not fully devoted to EM practice, but sufficiently manage minor emergencies. Patients with a non-scheduled urgent consultation can usually obtain an appointment within 24–72 h with their own doctor; otherwise, they can be visited the same day by another doctor from the center. Patients with mobility problems may be visited at home during the day by their general practitioner. In general, complementary immediate tests available in PCC are limited and usually consist of electrocardiography and blood and urine sticks.

During the past few years, effort has been made to provide more powerful diagnostic tools at this level. Today radiographies, dry biochemistry, blood analysis and pulse-oxymetry are provided in selected PCCs, with a specific location where emergency consultations are attended 24 h a day. Some PCCs are even equipped with small observation units to maintain patients up to 6-12 h if home discharge is anticipated. Doctors working in these new PCC emergency facilities are, in most cases, fully devoted to EM: in many cases they are not the PCC family doctors; rather, many are hired exclusively as emergency physicians (EP) to provide attention to these emergency consultations. Another important change in the concept of medical care has entailed moving from the primary care continuous attention concept towards a continuous emergency attention model. These new emergency centers are only partially available in the largest cities. Their effectiveness will help the administration to decide if this policy should be maintained or even expanded [13].

Spanish EMSs contribute hugely to guarantee population coverage in all situations. They are run by EM technicians (EMT), nurses and doctors who usually work exclusively in the emergency arena. Their role in big cities is essential, often providing continuous at-home services during PCC off-hours. Characteristically, the demand is greater on weekends and between 3–10 pm, probably influenced by PCC time tables. Respiratory problems are the main complaint treated by EMS [14, 15]. Despite concerns of EMS overuse due to their easy access, prompt response, at-home care delivery and zero cost to the consumer, it has been repeatedly demonstrated that EMSs in Spain are not used as a first option to enter the health care system [14‐16].

Public spaces are a major scenario for EMS for both minor emergencies and accidents, as well as mass casualties and catastrophes [17]. Spanish EMSs have faced major catastrophes in recent years, with the Madrid bombing terrorist attacks on 11 March 2004 being the largest. Extensive analysis and description of such actions have been published abroad [17‐20]. In this setting, the provision of health care with advanced cardiac life support (ACLS) units is crucial. Very recently, the distribution of ACLS units has been published [21]: in January 2009, Spain had 362 operative teams (327 corresponding to road transport ambulances and 35 to helicopter ambulances) operating at a ratio of 1 ACLS unit to 127,308 inhabitants (0.78/100,000 population) with ratios varying four-fold among different geographic areas. In addition, EMS can provide support for patient transportation in isolated areas from low- to high-tech hospitals. A recent study showed that, although exclusive internal hospital resources were used in 58.3% of transportations, 33.3% required a combination of their own services and outside suppliers provided by EMSs, and the EMSs were exclusively used by 8.3% of the hospitals [22]. Emergency medical service provided by helicopters, which include trained physicians and nurses in their crews, merits special mention because they ensure correct medical care and transfer from isolated geographic zones, especially in the archipelagos [22‐25]. Finally, coordination of medical care from EMSs is carried out in centralized centers where experienced doctors, nurses and technicians assign the best resource according to well-structured, computerized protocols.

EDs dealt with more than 25 million consultations in 2008, which implies, on average, that one out of two Spaniards visited an ED during this time. They are usually equipped with a wide range of diagnostic tools, most including ultrasonography and computerized tomography scans. Today the academic and training background of doctors working in the ED varies, although most work well in all types of emergencies because of full-time dedication to EM. Nearly half lack any structured specialty residency training, but many of them have done specific master or postgraduate studies within EM.

At the end of the 1990s Spanish EDs had some deficiencies, which were investigated and reported by Montero et al. in a series of papers [26‐28] evaluating nearly 200 Spanish EDs. The most relevant deficiencies were the following: heterogeneous hierarchic assignation of the ED within the hospital with less than one-half being considered a true department; the insufficient number of rooms in 40% of EDs, mainly in those located in the highest level hospitals; and the lack of complementary exploration/analysis facilities assigned exclusively to the ED in most centers. Additionally, they found a large proportion of the patients coming to the ED spontaneously, avoiding the remaining emergency extrahospital points of care. They also reported an excessive health care burden per ED at high-tech hospitals, while the community EDs were those proportionally worse off in human (physician) resources. Finally, they detected a non-adequate form of work, which for staff was usually 8-h shifts and night duties, supported by intern and resident physicians, mainly in their first or second year of training.

Since then, some efforts have been made to correct these ED deficiencies. An increasing number of EDs have achieved the status of independent hospital departments, their patient capacity has been raised, different strategies to re-direct patient flows have been approached and substantial increases in the number of ED staff have been made. Additionally, the work schedule is shifting in most Spanish EDs from a mixed model of 8-h shifts plus 24-h duties to a model exclusively based on 8-h or a maximum of 12-h shifts to match the European directives regarding work days [29]. However, these changes in work hours will need some additional years to be fully implemented in all EDs of the public health care system.

Unfortunately, all these changes have not been enough. The demand for emergency care at EDs has been growing at an annual rate of over 4% during the last decade, double the 2% population increase (mainly due to immigration [30]) registered during that period and surpassing the growth in hospital ED capacity [31]. Therefore, EDs become overcrowded when the system exerts minimal stress [32‐34], which has a clear impact on the quality of care provided [35]. It is, however, a seemingly unavoidable effect in all developed countries providing free universal health care and ED access [36]. This situation has prompted all the personnel involved to make changes to ameliorate this condition [37]. In an attempt to decrease ED arrivals, a partial payment for services has been proposed in some situations, especially when misused [38], as has patient diversion to other system resources [39], or an offer to call services for better guidance to thereby avoid a part of hospital ED consultations [40]. The rationale for such actions is based on the fact that in Spain, as in most other countries, around 30% of ED consultations are identified as inadequate demand, using objective tools of measurement [41‐43]. On the other hand, greater efforts have been made to adapt the physical structure and human resources to cope with this increasing demand [44]. One of the most remarkable initiatives has been the implementation of triage systems for prioritizing patient assistance based on the severity of their condition [45]. Spain has no common triage model. The Manchester, Canadian and Spanish systems are used widely across the country; the latter [Sistema Español de Triage (SET) or Spanish Triage System)] was specifically designed, developed and recommended by the Spanish Society of Emergency Medicine (SEMES) [46]. Most EDs have redesigned their circuits and patient flow to gain efficiency [47], although most of the benefits of these changes have shown to dissipate within only a few years [48]. In some instances, depending on the ED staff, specific observation and/or short-stay units have been launched [49, 50]. When measured, this model has proved to be more efficient than other classical management models [51‐54]. Another example of coordination among different emergency levels of actuation is the installation, in many big Spanish cities, of activation codes for certain pathologies (like acute myocardial infarction, stroke, polytrauma, sepsis), which have allowed improvement in quality and results [55].