Trauma care in Germany
Introduction
Trauma has a tremendous social and economic impact on the individual as well as on the entire society. For people under the age of 50 years, trauma-related deaths and injuries have been shown to have a greater socioeconomic impact than other conditions such as malignancy and cardiovascular disease. Especially in a modern, industrialised, highly mobile society such as Germany, the adequate treatment of trauma patients is a challenging task, both medically and economically. Not only do young and mobile people have to be covered by the trauma-care system in Germany, but also the number of injured elderly patients is increasing. In addition, as the recent past has shown, natural and technical disasters as well as acts of terror may result in mass casualties. Such disastrous events as Ramstein 1997, Eschede 1998, Enschede 2000 or New York 2001 make huge demands on a system of trauma care.
To meet all requirements, the trauma-care system in Germany is well organised and follows clear-cut goals:
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to reduce the therapy-free interval;
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to ensure highly qualified and effective prehospital treatment as soon as possible;
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to minimize transportation time;
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to transfer trauma patients immediately to an adequate-level trauma centre, where therapy is performed to the highest medical and technical standards available.
A broad variety of reasons may be responsible for the fact that the morbidity after trauma has decreased in recent decades. However, the system of trauma care in Germany has been proved to fulfil most requirements so far and has stimulated the initiation of similar rescue systems in neighbouring countries.
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Historical background
The social network, including mandatory health insurance (1883), accident insurance (1884) and pension insurance (1889), was designed by a former chancellor Otto von Bismarck (1815–1898). As a prerequisite, the employers provided the funding for the mandatory accident insurance only. It was anticipated that the employers would have a natural interest in trying to reduce their spending and thus would tend to contribute to preventative measures and so would support the financial environment to
Specific geographical and demographical constraints
In Germany, about 82 million citizens live in an area of 356,000 km2. To guarantee fast and professional aid by the rescue teams, there are about 400 rescue-coordination centres (Rettungsleitstellen) coordinating 854 physician-staffed ambulances and 52 physician-staffed rescue helicopters (HEMS) nationwide. Germany is divided into 326 ‘rescue areas’. A typical area covers nearly 1100 km2 with 2.5 million inhabitants, and on an average there are 3.7 physician-staffed, first-response, advanced
Current status
In 2000, 5.25 million accidents were registered as occurring at home or during leisure activities, at work, or as road-traffic accidents (RTAs). In total, 511,000 people were injured and 7503 killed, 6823 due to RTAs. The number of deaths decreased from 11,300 in 1991 to 7500 in 2000, whilst in the same period the number of injured fell by only about 2 % 34.
The incidence of penetrating injuries is one of the biggest differences between the USA and Europe: the general mortality from penetrating
The German approach to disaster management
As a public task, the government has shifted the responsibility for disaster control and disaster relief, as well as civil defence and civil protection, to the counties, due to the fact that Germany is a Federal Republic. Including the new counties, there are now 16 counties responsible for the legislation and organization of the following services: rescue, fire fighting and disaster control (both natural and technical disasters). This system is based on the principle of synergy between
Prevention, research and quality management
A number of factors may be responsible for the decrease of morbidity from injury over the last 20 years. These include a sophisticated rescue system, as well as technical improvements in cars and improvements in safety at work 37, traffic speed control, and better diagnostic and therapeutic tools. Last, but not the least, enormous efforts in accident and injury prevention, basic research and quality management have been undertaken at the Department of Trauma Surgery at Hannover Medical School.
Research
The German trauma system has undergone many changes. These changes were influenced by the results of clinical and experimental trauma research 7., 9., 10., 20., 21., 22., in cooperation with pharmaceutical and car-manufacturing companies. Furthermore, collaborations were forged between trauma centres in the USA and the Hannover Medical School, and the Department of Trauma Surgery has initiated many multicentre studies 5., 17., 23.. Recently, in Germany, the academic environment has changed.
Quality control and management
The ‘Multiple Trauma Working Group’ of the DGU founded the German Trauma Registry in 1993. The aims were to improve the quality and the definition of guidelines for the treatment of multiply injured patients. To date, 79 hospitals in Germany, 7 in Austria and 1 in Switzerland have documented 11,997 such patients.
All participating hospitals send their documentation sheets to three different documentation centres (Essen, Hannover, Cologne). There, all files are monitored for completeness and for
Summary and future perspectives
The efforts to create a sophisticated trauma system in Germany appear to have been rewarded; lethal outcomes have fallen from 40% to less than 20%. This success can only be maintained if extraordinary expenses are continued. Thereby, any reduction in the standards of trauma care due to a constrained financial environment must be avoided. It must be kept in mind that trauma represents the major cause of disability in individuals during their productive working lives 31., 32.. In addition,
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2016, Chinese Journal of Traumatology - English EditionCitation Excerpt :High mortality rates (50%–77%) have been reported for femoral shaft fractures associated with pelvic fractures and injuries to other systems.2 These injuries have a great impact not only on the social and economic life of individual, but also on the society.3 We present a rare case of bilateral unstable pelvic fractures (acetabular and sacral fractures), bilateral segmental femoral shaft fracture with multiple right rib fractures and associated haemothorax.
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2014, InjuryCitation Excerpt :As a recent study by Wyen et al. [6] demonstrated the so called “golden hour” is often failed in Germany although concepts which focus on reducing the pre-hospital time like Pre-hospital Trauma Life Support® (PHTLS) have been integrated into the training of physicians and EMTs [7]. Fast and continuous treatment – so called: “treat and run” – is top priority, while “load and go” approaches are considered a last resort [8–10]. There is no similar ground EMS physician system in the Netherlands.
Pre-hospital and in-hospital parameters and outcomes in patients with traumatic brain injury: A comparison between German and Australian trauma registries
2010, InjuryCitation Excerpt :Roudsari et al.19 provided insights into the international variability in patient mix, processes of care, and performance of different pre-hospital trauma care systems worldwide; however, the analysis was not TBI-specific. Germany's EMS is an example of a system where physician-operated advanced life support (DOC-ALS) EMS run the majority of pre-hospital acute trauma care and are utilised more frequently as compared to other developed countries.18,24 In contrast, in Anglo-American emergency medical systems such as Australia, an alternative EMS has developed in which highly trained paramedics are deployed on road and air for acute trauma care at the scene and for transport.