As part of the World Bank loan, in 2009, the Development of Emergency Medical Services (EMS) and Investment Planning Project was started providing the Republic of Croatia with a single emergency medicine system: providing a uniform, faster, more accessible and effective emergency medical service to patients, and better working conditions and professional training for health care professionals. The project encompassed all aspects of emergency medicine since the establishment of county institutes of emergency medicine and emergency departments, establishment of medical dispatch units, renewal of the pre-hospital EMS fleet and the introduction of specialization in emergency medicine, standardization of procedures, training, medical equipment, devices and equipment in emergency medicine.
The emergency medical service in the Republic of Croatia has been organized according to the model of a collaborative and single system of pre-hospital and hospital EMS and the Croatian Institute of Emergency Medicine, and the establishment of such an emergency medicine system has ensured efficient and quality provision of emergency medical care for everyone within Croatia.
Taking care of emergency patients is a great responsibility, both for healthcare professionals and for the entire health system. Prescribing standards and training programmes as well as optimal conditions for the performance of emergency medical services (EMS) is the basis for the establishment of a quality system and a quality management system and is an upgrade to the Ordinance on the minimal requirements regarding the space, workers and medical technical equipment for the conduct of emergency medicine activities (OG 71/2016). These are: Standard for medical equipment, medical devices and equipment for performing pre-hospital emergency medicine, Standard for vehicles and the exterior appearance of vehicles for performing pre-hospital emergency medical services, Standard for protective workwear, footwear and personal protective equipment for pre-hospital emergency medicine, Standard for medical equipment, medical devices and supplies for hospital emergency medicine and pre-hospital emergency medicine training programmes and training programme for basic training exercises for workers performing triage in emergency medicine, established by the Croatian Institute of Emergency Medicine. These standards and training programmes, each on its own, combine regulations and rules governing the way of emergency medicine activities are performed, for the purpose of adapting the emergency medicine system to the equivalent European and international systems and contemporary scientific standards in order to ultimately make a significant contribution to a more quality approach to patient care in this important and sensitive activity. Their adoption has transformed the previously diverse work practice in the emergency medicine system into a new single concept of work which is the same and binding for all institutions providing emergency medicine in the Republic of Croatia, while the CIEM will monitor their implementation.
Pre-hospital emergency medicine services (EMS), i.e. emergency medical care for patients prior to hospital admission, is within the domain of county institutes of emergency medicine, and each of the institutes monitors, coordinates and organizes the work of its teams within the county and cooperates with the institutes of the neighbouring counties, according to schedule of the EMS teams established by the Emergency Medicine Network (OG 49/2016 and OG 67/2017).
Medical dispatch units coordinate the emergency medical service (EMS) teams in the field and operate within county institutes of emergency medicine. Modern medical dispatch units cover the entire territory of a particular county, with the possibility of communicating with neighbouring counties thanks to horizontal and vertical communication and computer networking. Also, the TETRA communication system has been implemented in the medical dispatch units, enabling greater geographic reach and better signal coverage and, along with network connections with other counties, it includes a network connection with the Crisis Centre of the Ministry of Health, the Croatian Institute of Emergency Medicine and emergency department. Such an organization of the medical dispatch units allows for continuing monitoring of the entire pre-hospital emergency medical services 24/7.
Each county medical dispatch unit has healthcare professionals - medical dispatchers who, apart from medical, also have basic psychological skills to calm the citizens who call them in extremely stressful situations. The job of a medical dispatcher in medical dispatch units may be performed by a medical doctor specialist in emergency medicine or a doctor with at least two years working experience in a pre-hospital emergency medical team or a Bachelor of Nursing with at least four years of work experience in a pre-hospital emergency medical team or a nurse with at least six years of work experience in a pre-hospital emergency medical team. Given the importance of the impeccable functioning of the medical dispatch units, the Croatian Institute of Emergency Medicine has prescribed training programmes in pre-hospital emergency medicine under which training of medical dispatchers is conducted.
Emergency Medical Service (EMS) is reached by dialling 194. Receiving emergency calls is based on the Croatian index for receiving emergency calls for medical dispatch units, thereby standardising the receiving method in all Croatian counties, and enabling callers to make direct contact with medical dispatchers. This ensures optimal use of resources, as well as documentation of accidents and events that endanger the health and life of citizens. The Index presents guidelines for the work of medical dispatchers in medical dispatch units that allow them to correctly and consistently assign priorities to each incoming emergency medical call. The question regarding the main problem that the dispatcher asks the caller determines the degree of urgency, which is why dispatchers should therefore be allowed to guide the caller through the conversation. Symptoms with the first degree of urgency require the EMS team to provide an urgent response in the field, symptoms of the second degree offer the possibility of delaying the provision of emergency medical care (if there is a more urgent patient), while callers with symptoms of the third degree of urgency are directed to consult a general/family practitioner. At all times, medical dispatchers see all vehicles and all teams in the field and always send the nearest vehicle to an emergency intervention.
The questions asked by a medical dispatcher are necessary to help patients get help as quickly as possible when they need it. Different people react differently in stressful situations and should therefore allow the dispatchers to guide the caller through the conversation. As they enter the data, the emergency medical service (HMS) team has already gone to the patient. Although the medical dispatch unit has the ability to identify the number of the incoming calls, for the sake of having correct information, it is necessary during the call to indicate the address where the caller is located, their telephone number and their first and last name. In this case, even if for some reason the telephone connection is lost, the EMS team in the field will know the location where they need to go and on which number they can contact you again.
Conversations with medical dispatchers in the medical dispatch units are recorded, and their contents are an official medical secret and are treated as such.
Emergency Medical Service (HMS) is called by dialling 194 when life is directly threatened, or health is severely impaired. Emergency medical conditions are: sudden onset of difficulty breathing; choking on a foreign object; cardiac and respiratory arrest; loss of consciousness; sudden chest pain; sudden quickening or slowing down of the heart rate or irregular heart rate; cramps (convulsions); impaired speech, weakness or paralysis of part of the body, distortion of the face; injuries caused by traffic accidents and other sudden injuries (fall from a height/animal bites/stings/shootings, etc.); unusual bleeding on any of the natural body orifices; burns; electric shock or being struck by lightning; hypothermia, heat stroke; drowning; poisoning with medication/narcotics/chemicals; strong allergic reaction; sudden and unusual pain (severe headache, severe chest pain/abdominal/back pain); sudden changes in behaviour that endanger the patient or the environment (attempted suicide/murder, etc.). It should be kept in mind that any unnecessary or fake call occupy the telephone line and prevent those whose lives are endangered receiving EMS assistance. The response time and availability are decisive factors of EMS efficiency, while taking care of non-urgent conditions takes the time of the EMS team on their way to respond to a necessary intervention. Emergency conditions requiring immediate medical care have also been described in the leaflet Emergency Medical Service - Everything you need to know, which can be found here.
A busy telephone line means only that a medical dispatcher is talking to someone who also needs urgent help.
In cases where there is no direct threat to someone's life or their health is not seriously compromised, emergency medical service teams do not go out to the field. In this case, the medical dispatcher will advise you on what to do and who to contact for help.
Follow the instructions given by the medical dispatcher. Try to remain calm and calm down the patient, make them warm and keep them awake. Do not give them anything to drink or eat. If the patient has fallen from a great height, has experienced a traffic accident, or is unconscious, do not move them unless they are in immediate danger, such as fire, explosion, drowning. If you can, begin providing first-aid measures.
The emergency medical service team will find you more easily if you turn on your front lights or illuminate the house number or send someone to greet the team. You can also free the passage to the patient - close off pets, remove furniture, flowers, parked cars and, of course, prepare medical records.
Every patient has the right to privacy and this right is respected. In addition, the presence of other persons may adversely affect the condition of the patient as well as the ability to provide the patient with care (for instance, due to vehicle capacity). Finally, the escort should not be exposed to risks. The doctor has the knowledge and skills, and the right and obligation to undertake all available medical procedures in order to take care of the patients and their welfare. Exceptionally, if a patient is a child and/or a person with a disability, an escort is permitted.
The organisation of emergency departments with a corresponding work process in taking care of emergency patients and with appropriate equipment and specialist workers ensures the provision of higher levels of health care to emergency patients. Prior to the emergency medicine reform, the admission of emergency patients in Croatian hospitals took place through various specialist sections, which was especially a problem in patients with multiple symptoms and injuries. By establishing emergency departments within hospitals, a single-entry point for all emergency patients was created, available for providing 24-hour hospital emergency medical care in the form of examinations, diagnosis and treatment. The emergency department consists of a patient admission area, and an area for examinations, diagnosis and treatment. By adopting the Standard for medical equipment, medical devices and equipment for performing hospital emergency medicine, the emergency department structure and premises have been defined and the prerequisites for the purchase of standard equipment and devices for all the hospitals have been established, while the training programme for basic training exercises for workers performing triage in emergency medicine enabled conducting single triage of patients arriving at the emergency department according to the degree of urgency. Such uniformity ensures the same level of hospital emergency medical care in all hospitals with emergency departments in the Republic of Croatia.
Emergency medicine specialization is necessary and specific as it combines the knowledge and skills of various specialties, i.e. the urgency of all branches of specialization and pre-hospital and hospital emergency medicine. The specialization lasts five years, and the programme is fully aligned with the European emergency medicine specialization programme.
The specialization can be done in healthcare facilities that have approval for carrying out emergency medicine specialization, and in accordance with the Ordinance Regulating Specialist Training for Doctors of Medicine (OG 100/11, OG 133/11 and OG 54/2012).
According to the Croatian Institute of Emergency Medicine data, an outstanding 70 percent of patients who seek help, whether from pre-hospital or hospital emergency medical services (EMS), are non-urgent patients. Since the emergency medicine system does not have unlimited resources, a large percentage of non-urgent patients slows down EMS response time and endangers the lives of people who have an actual real emergency. An important prerequisite for unburdening the EMS is to inform and educate the public, explaining that emergencies are situations that directly threaten life or health. Therefore, a few years ago we launched a public awareness campaign on the scope of work of the EMS, within which we also prepared an educational leaflet Emergency Medical Service – everything you need to know. Although some county institutes of emergency medicine have been able to achieve some positive results with great efforts and work in the field, the problem is still present, and the campaign is still ongoing. All citizens, if they are not sure whether their condition is urgent, can always contact the medical dispatcher by dialling 194, and they will give them instructions for further action. Along with medical dispatchers, people should also contact their family doctor because in case of non-urgent conditions, it is precisely their family doctor who can give them the best advice and provide appropriate care and teach them how to act when their disease gets worse. Distinguishing between urgent and non-urgent conditions can significantly reduce patient inflow and the pressure on EMS and provide emergency health care to those whose lives are truly threatened.
With the education of the public, for the purpose of ensuring timely health care for all patients and improving the work process and the availability of EMS, it is necessary to introduce changes in the manner and organization of work of all primary health care stakeholders to rationalize the existing human, material and financial capacities within the health system.
The Croatian Institute of Emergency Medicine (CIEM) has adopted training programmes (OG 80/2016) for professionals in hospital and pre-hospital emergency medical services (EMS). Training programmes in pre-hospital emergency medicine define the content of training for dispatchers in medical dispatch units, for medical doctors in pre-hospital EMS teams, as well as for nurses and for drivers in pre-hospital EMS teams. Each programme describes in detail the competences, and the knowledge and skills that the participant gains with the successful completion of the same and the way it is organised and implemented. The training is provided exclusively by national instructors for medical dispatch unit dispatchers, or for pre-hospital EMS professionals who have a valid CIEM certificate. All training must be reported to the CIEM, while the instructions and the training registration form are also listed in the training programme in special annexes. These annexes also include training exercises for each individual programme and the equipment needed for them in order for the training to be performed well and efficiently.
The training programme for basic training exercises for workers performing triage in emergency medicine determines the content of training for nurses performing triage work in emergency departments and the competences they acquire through the successful completion of the training programme. The programme encompasses basic training exercises and knowledge and skills refresher exercises that enable nurses to acquire and maintain the competences required to conduct triage of adults and children in emergency departments. Also, the training programme prescribes the manner the training is organised and implemented, as described in detail in the Programme annexes. The CIEM issues the decision to implement the training, which can only be conducted by national triage instructors with a valid certificate of the Institute. Nurses who carry out triage in emergency departments must refresh the acquired knowledge and skills before the expiration of a period of three years from the date of issue of the certificate issued by the CIEM after the successful completion of the training programme. This ensures efficient and quality care of emergency patients and reduces the possibility of adverse events, mortality and disability.
The CIEM also implements the project Continuous professional training of emergency medicine workers with the aim of maintaining and improving the knowledge and skills of emergency medicine workers, while at the same time improving healthcare in the Republic of Croatia and improving access to high-quality health services. The project with the total value of HRK 9,414,904.10 is co-financed by resources from the European Social Fund, and a total of 62 courses will be conducted to train 1824 workers in the field of emergency medicine through five training programmes (EP): EP1 for medical dispatchers, EP2 for doctors as well as nurses in pre-hospital EMS, EP3 for pre-hospital EMS drivers, EP4 for workers performing triage in emergency medicine and EP5 for nurses in emergency departments.
The growing possibilities of major incidents and, unfortunately, a constant potential threat of terrorism, remind us of the importance of planning and the necessity of ongoing medical care training in order to respond well, properly and effectively to complex emergencies and mitigate their consequences. The Medical Response to Major Incidents - Cro MRMI course include the introductory theoretical lectures and practical training for decisions making at all levels in the event of a terrorist attack. Through table-top exercise a large incident is simulated, and its remediation and taking care of a large number of injured requires vertical and horizontal coordination of all the actors involved, including pre-hospital and hospital emergency medical services, other emergency services and a crisis centre as the central point for crisis management.
Along with the Croatian Institute of Emergency Medicine, the course organisers are the Croatian Disaster Medicine Association, General hospital "Dr. Josip Benčević" Slavonski Brod and the Crisis Centre of the Ministry of Health.
The Emergency Medical Service (EMS) is of particular importance during the tourist season when there is a significant increase in road traffic intensity as well as an increase in the number of visitors and guests on our coast and islands. Frequent traffic jams caused by increased road traffic intensity are often associated with traffic accidents, so the number of EMS interventions doubles during the summer. In addition to regular EMS teams, in order to increase safety on the roads during the summer season, the Croatian Institute of Emergency Medicine provides additional EMS teams situated on busy locations along the Croatian roads.
The Emergency Medical Service (EMS) is of vital importance for the preservation of the health and life of the islanders and their tourists. Emergency patients are currently transported from the islands by ferries, boats, medical transportation vessels or those of the coast guard, which are not adapted for medical transportation. Therefore, the Ministry of Health, in cooperation with the Croatian Institute of Emergency Medicine (CIEM) and the Ministry of Sea, Transport and Infrastructure, launched the project Establishment of maritime emergency medical services on high-speed vessels under the Competitiveness and Cohesion 2014 - 2020 Operational Programme of the European Regional Development Fund. The objective of the project is to reduce the response time for interventions, increase availability and achieve equality and improve the quality of the provided emergency medical services which will be implemented for the needs of emergency medical transportation from the islands. At the same time, such a service would also be available to provide emergency medical care of maritime incidents and disasters, for transporting medical personnel and strengthening cross-border healthcare in line with the European Directive (2011/24/EU).
Following a public tender, in accordance with the Competitiveness and Cohesion Operational Programme, the CIEM ordered a feasibility study which covered all aspects of the project whereby EMS in Croatia would be provided by sea via specialized vessels with the necessary equipment. The study has determined it is necessary to acquire six high-speed boats to be located in Dubrovnik, Mali Lošinj, Rab, Supetar, Šibenik and Zadar. In October 2018, the CIEM concluded a Cooperation agreement for the preparation and implementation of the EU project Establishment of maritime emergency medical services on high-speed vessels with the county institutes of emergency medicine of the Dubrovnik-Neretva, Primorje-Gorski Kotar, Split-Dalmatia, Šibenik-Knin and Zadar counties. The agreement is based on the agreement of the same name concluded between the Ministry of Health, the Ministry of the Sea, Transport and Infrastructure and the CIEM, whereby the county institutes committed themselves to regulating mutual relationships regarding the preparation and implementation of the activities related to the application (drafting of the project proposal) and implementation of the project.
In April 2019, the Croatian Ministry of Health allocated a total of HRK 45 million of grants from the European Regional Development Fund for the purchase of six high-speed vessels to be equipped for the care and transportation of emergency patients accompanied by the EMS team and for contracting their berths at their home ports in the Adriatic, as well as for twelve biochemical blood analysers for urgent diagnosis on the islands. Automatic biochemical blood analysers will be distributed to 12 substation of the emergency medicine institute of the Dubrovnik-Neretva, Primorje-Gorski Kotar, Split-Dalmatia and Zadar County (Blato, Korčula, Lastovo, Mljet, Cres, Mali Lošinj, Rab, Jelsa, Vis and Preko). The procurement process is ongoing.
In the absence of a specialised Helicopter Emergency Medical Service (HEMS), for greater availability of emergency medical care to patients on islands and patients in other distant and poorly connected areas, there is a long-term Cooperation Agreement on the implementation of emergency air transport in the Republic of Croatia between the Ministry of Health and the Ministry of Defence. This agreement ensures helicopter airlift with medical teams for the care and transportation of patients whose lives are threatened or sick patients year-round, with bases in Divulje and on the island of Krk. Also, through co-operation of the Ministry of Health, the Ministry of the Interior and the Dubrovnik-Neretva County during the tourist season an HEMS is also organized, based in Dubrovnik. This ensures greater availability of adequate emergency medical care for residents and visitors of island, rural and poorly populated areas of the Dubrovnik-Neretva County. A Ministry of Interior helicopter is used for flights, while the medical team is ensured by the Ministry of Health.
The main role of HEMS is to take care of severely injured or critically ill persons in the shortest time possible through primary flights, i.e. flights flying directly to the scene immediately upon receipt of the call and where the medical team from the helicopter alone or together with the ground team carries out the complete intervention. It is also the only way to reduce the time until starting to take care of an emergency patient on site and at the hospital. The Republic of Croatia has recognized at the highest levels the importance of establishing HEMS and a working group of the Ministry of Health, which includes representatives from several ministries, is working intensively to define the most efficient and financially sustainable model of HEMS as soon as possible for the long-term benefit of our citizens and tourists.
Telemedicine is defined by the World Health Organization as providing long-distance healthcare services using information and communication technologies that exchange information important for diagnosis, treatment and prevention of illness and injury, information important for research and evaluation, as well as continuing education of healthcare professionals with a view to improving the health of individuals and their communities. Thanks to the provision of remote healthcare services, patients no longer need to go to a hospital with specialists in order to get professional advice or treatment for their health condition.
Medical services included in the digital exchange of findings, images, readings, diagnosis, remote treatment and second opinions are mainly from the fields of radiology, cardiology and neurology, as well as others. The range of telemedicine services is constantly expanding thanks to technological innovations that are often redefined and perfected in the process of application and are continually improving and adapting to healthcare requirements. Telemedicine services are provided at the primary, secondary and tertiary level of health care.
The Croatian Institute of Emergency Medicine (CIEM) provides telemedicine services within the telemedicine centre network adopted by the minister of health, which guarantees equal availability of health services throughout the entire territory of the Republic of Croatia. The equipment, computer and communication infrastructure, for each telemedicine centre, is supplied, configured and installed by the CIEM Telemedicine Section, which also trains healthcare professionals to use it. In their premises the central server is also located, where network monitoring is performed, and technical support provided to all telemedicine centres 24/7.
Telemedicine services can be received in telemedicine access centres which usually include a general practitioner, nurse or medical radiology engineer, while telemedicine specialist centres are the location of receiving and providing telemedicine services according to specialty. Telemedicine service recipients and providers include various health facilities, from clinical hospital centres in major cities to outpatient clinics. Since their founder is the Republic of Croatia, regional self-government or local self-government unit, they make up the basic telemedicine centre network and have a contract with the Croatian Health Insurance Fund. The expanded telemedicine centre network includes healthcare companies and private healthcare providers who perform telemedicine, and who have previously acquired the conditions for work prescribed by the CIEM Telemedicine Section.
The procedure for ordering telemedicine services is the same as the procedure for ordering specialist exams or face-to-face examinations. The service is sought by the primary health care physician for the patient based on referral given to them, while the teleconsultant, i.e. a doctor or specialist, provides the requested service. This service may be scheduled, urgent or supervisory.
A telemedicine examination is the same as a regular examination by a doctor, except that it takes place by communicating with a teleconsultant, a doctor or a specialist through a video connection - a screen and camera. The teleconsultant with whom you have an agreed examination will receive your medical information in advance, and during the exam, you will be accompanied by healthcare workers qualified to work with telemedicine equipment to show your health condition to the remote teleconsultant through specific medical equipment needed for your examination.
A telemedicine examination is private and confidential, just like a regular medical examination. The data can be seen and heard only by the patient and their possible escort and by the healthcare workers involved in the examination.
All expenses, except for compulsory participation in the health insurance costs of the insured, are covered by the Croatian Health Insurance Fund.
Telemedicine is a necessary modern healthcare tool and the only solution that ensures the availability of top-level specialist healthcare services to all patients, even those in difficult to reach locations and islands, which is of particular importance for emergencies. Among the many advantages of telemedicine, patients and doctors most frequently point out timely diagnosis and treatment, improved health outcomes, less travel, saving time and costs through faster information transfer or data delivery. We can still add to these benefits improved co-operation among doctors, as well as the possibility of systematic training of healthcare professionals. All of these factors have an impact on improving the quality of healthcare provided, but also on improving the overall healthcare system.
