injury-2003-trauma care systems in belgium

8/13/2019 Injury-2003-Trauma Care Systems in Belgium

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Trauma care in Belgium 1 (version 11-06-2003)

Trauma care in Belgium.

Stefaan J.B. Nijs, MD and Paul L.O. Broos, MD, PhD, FRCS

(Dpt. of Traumatology, U.Z. Gasthuisberg, K.U. Leuven)

Corresponding author:

Dr. Stefaan Nijs

Dpt. Of Traumatology

U.Z. Gasthuisberg

Herestraat 49

3000 Leuven (Belgium)

Phone: +32 16 34 46 66

Fax: +32 16 34 46 14

e-mail: [email protected]


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Geography and demography

Belgium is situated in the west of Europe, bordered to the north by the

Netherlands, to the east by Germany and the Grand Duchy of Luxembourg

and to the south and the west by France. Although its surface area of 32,545

km2makes it a small country, its location has made it the economic and

urban nerve centre of Europe. "Belgium, heart of Europe" is not just a catch

phrase: the geographical centre of the 15 countries of the European Union is

actually located in Belgium and more precisely in Oignies-en-Thirache

(Viroinval), in the province of Namur .[1]

The Belgian state has a federal structure. The decision-making power in

Belgium is no longer exclusively in the hands of the Federal Government

and the Federal Parliament. Nowadays, the management of the country falls

into several partners, which exercise their competences independently in

different fields. The state is divided in three communities based on linguistic

and cultural issues: the Flemish-, the French- and the German-speaking

community. Furthermore, the country is divided in three regions on a more

historical and economical base: the Flemish region, the Brussels capital

region and the Walloon region. The federal state retains important areas of

competence including: foreign affairs, defence, justice, finances, social

security, important sectors of public health and domestic affairs, etc. The

regions and communities are entitled to run foreign relations themselves in

those areas where they have competence. The public health and social


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security competence are not only shared by the federal and regional

governments, but they are within each structure also shared by different

ministries. This partition of competences in different persons and levels

makes it often difficult to interact with the government.

On 1st January 2001, Belgium had 10.263.414 inhabitants. This means a

population density of 336 inhabitants/km2 which makes Belgium one of the

most crowded countries of Europe. Flanders has 5.952.552 inhabitants (440

inhabitants/km2), the Walloon Region 3.346.457 (198 inhabitants/km2) and

the Brussels Capital Region 964.405 (5953 inhabitants/km2) [1]. These

differences reflect on the development of the regions. Flanders is

characterized by a spread of the population over the entire surface. Even in

the more rural regions, the streets are bordered by houses, which are not

concentrated in villages alone. This makes that there is a close interaction

between traffic and living space over the entire surface. Wallonia has a more

rural aspect. Its population lives more concentrated in towns and villages.

On the other hand, it traditionally has the heavier industries, which are

related to a relatively higher number of and more serious labour accidents.

The Brussels Capital Region is a typical city region with a dense interaction

between the living space and traffic at a lower speed, but also by relatively

more criminality. This means that the need for trauma care is relatively

different in the three regions.


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Traditionally the French-speaking community is oriented on the French

culture, the Flemish more on the Anglo-American and German culture. This

is also reflected in the scientific - including the medical - world, where

Flemish medicine is based on an Anglo-American and German (Central-

European) and Walloon medicine on a French (Southern-European)

tradition.

Pre-hospital care

Before 1956, there was no organized medical field support. The local doctor

tried to give some support to the trauma victim. Although some local

hospitals offered transportation using their own ambulances, the most often

used means of transportation were taxis and private cars. In 1956, the first

governmental organisation of medical transport was founded, creating the

national rescue service for transportation of poliomyelitis patients. The

law of 8th April 1958 obliged the municipalities to provide transportation to

all persons in need of urgent medical care caused by accidents or illness on

a public road or public space. A public space was defined as all places that

cannot be considered as a private home [2].

The same year, an investigation researching the needs and conditions to start

up a national service for urgent medical support was initiated. The process

was urged after some painful experiences, such as the disaster in the mari pit


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Roosberg in Zichem-Zussen-Bolder. On 23rdDecember 1958, the pit

collapsed and seventeen workers got isolated. It took a long time before any

rescue operation was initiated, all workers died and only four corpses could

be retrieved. The event was considered as a national disaster and the King

and the minister of public health, Paul Meyers, did visit the area. On his way

back to Brussels, the minister witnessed a serious accident in which a

female pedestrian was hit by a car. Again, it took a long time before any

rescue service reached the scene. Some sources mention that the Minister

would have stated that such thing should not happen again and that he

ordered his administration to give the development of a national service for

urgent medical support highest priority [3].

In 1959, the first help centre 900 became active in Antwerp. Nationwide,

15 extra centres were installed between 1959 and 1963. It was recognized

that the municipalities didnt have the possibilities to organise the urgent

medical support and the transportation of injured and acute ill persons did

become a task of the Department of Home Affairs starting from 1stJuly

1965. A central telephone number, 900, could be used nationwide to

activate the rescue system. In that way, one of sixteen help centres, located

in fire stations and manned by firemen was reached. Although the 900

help centres were legally only responsible for the evacuation of ill or injured

persons on public spaces, they soon started giving support to all medical

emergencies. In 1986, 50% of all interventions in the region of Hasselt were


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interventions in private homes. Only in 1998, this situation was recognised

in a changed law. Starting from 1st

January 1998, all emergency

interventions are legally the domain of the 100 intervention teams. In

November 1987, the number 900 changed into the number 100 because

of technical reasons. Beside the number 100, the European rescue

number 112 is in use since 1996 [4].

At the moment, 10 help centres 100 are active in Belgium, one per

province. They are almost all localised in a fire station. This means that six

of the initial sixteen centres have been closed in 1997. This has been an

issue of intense debate and still is discussed by some officials. The

Department of Home Affairs is - as already mentioned - responsible for the

arrangement and the functioning of the help centres. The Ministry of Public

Health and Environment is responsible for the organisation, the medical

equipment and the teaching of the EMTs (Emergency Medical Trainee).

All calls to the 100 or 112 centres are recorded on tape, mentioning

hour and date. All the 100 centres are connected and deal with the calls

making an intervention of the fire-brigade, EMTs and the Civil Protection

necessary. They are also a pivot in the provincial disaster management

planning. When one calls the 100, the telephone operator will send all

necessary help to the scene: EMTs, MUG (Mobile Emergency Team), fire

brigade, . The help centre will also inform the police over a direct line

when estimated necessary. Operators are firemen, most of them lacking a


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specific training. They use a standard protocol gathering the necessary

information [5].

In case of accident or illness, the operator can send an ambulance with at

least a driver and an helper on board. Both are trained EMTs. This means

they need to have a basic EMT training (120 hours, of which 18 hours

dedicated to the treatment of the injured patient) and to follow additional

trainings (24 hours/year) in recognised provincial training centres on a

regular base. Every five year, the EMT has to prove his theoretical and

practical skills in a test. Law has defined the external characteristics of the

ambulance. The equipment is not defined, because the European Standard

for Medical vehicles and their equipment which was introduced in 2000

got no legal character yet. Until recently, the Ministry of Public Health

provided the different 100 services with ambulances. This policy has been

abandoned because of budgetary reasons. Now, every 100 service has to

buy its own ambulances, according to its financial possibilities. Ambulances

are managed and manned by hospitals, private enterprises, the Red Cross

and in the first place by the fire brigades. Both professionals and volunteers

man the ambulances. In Brussels, an ambulance and MUG team of the army

intervene in those cases where severe burns are expected since the burn unit

is located in the military hospital [6].

In those cases where the operator expects that urgent medical support is

needed, he can send a doctor at the scene. The operator has the right to send


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no matter what physician at the scene to provide first medical support, but

he will preferentially send one of the recognized MUGs (mobile emergency

team). These MUG teams are linked to a recognized emergency department

of a hospital [7]. It consists at least of an in emergency medicine trained

medical doctor and a trained (male) nurse. Apart from criteria for the

external characteristics, the equipment is also legally defined. The mission

of these MUG services was designated by the Order in Council of 10 th April

1995 stating: the MUG is a hospital function, the aim of a MUG is the

reduction of the therapy free interval by going at the scene on the demand of

the 100 operator, the execution of all necessary medical and nursing care at

the scene and the supervision during hospital transport [8]. The function of

the MUG is further organised according to the Order in Council of 10th

August 1998 stating that the recognition of a MUG service can only be

awarded to an hospital with a recognised specialized emergency department

[9]. The medical head of the department must be a medical specialist in

emergency medicine. To becomea medical specialist in emergency

medicine, one must follow an additional training of 2 years after a

successfully completed training in internal medicine, anaesthesia or surgery.

The head nurse responsible for the nursing tasks must have a postgraduate

training in emergency and intensive care medicine. The medical doctor

leading an intervention must be a medical specialist in emergency medicine,

a specialist in training to become specialist in the emergency medicine or at


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least to have obtained the certificate acute medicine. This is an additional

training consisting of a theoretical training of 120 hours and a practical on-

site training of 240 hours, including at least 10 potentially life saving pre-

hospital interventions.(Ministerial Council of 12th November 1993). The

nurse must have a postgraduate training in emergency and intensive care

nursing or have at least five years of experience (gained before 1998) in an

emergency department. The personnel in active MUG service should be

immediately available and although they may have active duties in the

emergency department they should immediately be replaceable in these

duties by equally trained personnel. At the moment, 79 MUG services are

active. According to the programmation legacy, this number should be

reduced to 72, but the current minister of Public Health declared he couldnt

accept this reduction and wanted to augment the number to 81 [10]. The

programmation of MUG services according to the Order in Council of 10th

August 1998 foresees 1 MUG per administrational district and an additional

1 per 150.000 citizen.

According to the Order in Council of 10th August 1998, the victim has to be

transported to the nearest hospital with a recognized emergency department

[9]. The medical doctor of the MUG can ask the 100 operator to make an

exception on this rule in case of:

1. a disaster leading to an overwhelming of the caring capacities of thenearest hospital.


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2. when the victim or ill is - because of his/her medical condition - inneed of specific diagnostic and/or therapeutic means as mentioned in

the protocol (article 4, 6, Order in Council 10th August 1998)

3. when the treating physician, present by the ill, confirms that the illhas a medical record concerning the specific pathology of which

he/she actually suffers, in a hospital of the intervention region and

this hospital has a recognised emergency department.

This exception should be granted by the 100 operator according to the

protocol and according to the available means [11]. The nearest hospital is

meant in time as stated in the Order of Council of 08 th July 1999. The

protocols mentioned have to be drawn up by the provincial commissions on

urgent medical help. These commissions were founded in 2000 and started

functioning in 2001. The form HA 01 of the provincial commission for

emergency medical help in the province of Antwerp which is in use since

05thNovember 2001 mentions as reasons for exception: CO-intoxication,

Neurosurgery, Invasive Cardiology, Burns, Obstetrics and Paediatrics[12].

Notice that neither polytrauma nor any other trauma related causes (except

neurosurgery) are mentioned in the list! The physician of the MUG service

does not have to use this form and can ask for further exceptions.

A function specialised emergency department was created by the order of

Council of 27th April 1998 [13]. In this order, a number of structural,


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functional and organisational requirements are listed. One of the aims was

to limit the number of recognised - and thus in the 100-system functioning -

emergency departments. This should lead to improved care by concentrating

patients, experience and means, and should economize because of the same

reasons. Discussing the structural and functional requirements goes beyond

the scope of this article. Mentionable are the necessity of an ICU-unit of at

least 3 beds, a polyvalent operation theatre, a radiography department and

clinical biology. The head of the department should be, as for the MUG

function, a medical specialist in emergency medicine. Both functions (head

of the specialized emergency department and head of the MUG) can be

gathered in one person. A specialist in emergency medicine, a trainee in

emergency medicine or a physician having obtained the certificate acute

medicine should secure the medical supervision of the department 24 hours

a day. The physician supervising the function specialised emergency care

cannot supervise any other function at the same time with the exception of

the supervision of the MUG, when he can be replaced by a physician on

call, having the same qualifications, within 15 minutes after leaving the

emergency department. As long as this physician on call does not replace

him, the physician supervising the ICU should replace him. The supervision

should be guaranteed 24 hours a day. The supervising physician should

always be able to call a physician in one of the listed specialities:

internal medicine


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surgery

anaesthesiology

radiology paediatrics orthopaedic surgery gynaecology obstetrics otorhinolaryngeology

ophthalmology

psychiatry neurology

The physicians mentioned in this list should be available on call. It is

nowhere mentioned that they should be only on call for one hospital! In the

praxis, they often are on call for more than one emergency department.

Concerning the nursing staff, it is stipulated that the head nurse should have

a postgraduate training in emergency and intensive care nursing or should

be head of the emergency nursing staff for more than five years. Every

moment, at least two nurses should be present, one of them having a

postgraduate training in the emergency and intensive care nursing or having

an experience of at least 5 years in one of these departments on the moment

of the Order in Council. Although it was the aim to limit the number of

specialised emergency departments to 70 100 departments nationwide,

actually 148 departments got recognised.


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Intra-hospital care

Apart from the above-mentioned recognition criteria for the specialized

emergency department no legislation whatever on intra-hospital triage,

treatment and/or inter-hospital transfer of the injured exists. It is left to the

sole judgement of the physician what he should or should not treat.

Concerning this judgement, one should notice the fact that the Belgian

medical rewarding system is strictly act-related and that the technical act is

rewarded far more than the intellectual one .

No specific trauma-surgery is legally recognised or protected. In most

hospitals an ad hoc formatted group of physicians treats the injured. The

formation of this group passes too often ad random or at least unstructured.

Only some hospitals have a specific trauma surgery unit or a trauma team.

Even a structural trauma protocol fails to exist in most hospitals.

After the hospital stay, specific revalidation possibilities are scarce. Some

hospitals do have a specific revalidation unit, but in this unit cardio

revalidation, stroke revalidation, orthopaedic and trauma revalidation all get

mixed. The therapy is guided depending on the available place and the

interests of the leading physicians and physiotherapists.

Results


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Only partial information on incidence, treatment and outcome of trauma in

Belgium is available. The best source of information are the statistics of the

Belgian Institute of Traffic Safety (BIVV) [14]. Data on home, work and

sports related trauma are completely lacking. No national trauma

registration exists. Medical insurance information is distributed over a lot of

participants and not available for research.

Traffic related mortality in Belgium is high. During the year 2000, 1470

people died on the Belgian roads. This averages 4 a day! It means that

13.9/100000 citizens/year die on the road. When we compare this to our

neighbouring countries Belgium scores badly (table 1). When we look at the

trend since 1972 (last year before the global energy crisis and important

safety measures), we see that the number of deaths halves although the

number of vehicles doubles and the number of vehicle-kilometres almost

triples.(table 2) Important measures in the reduction of trauma deaths were

the safety belt obligation, speed reduction, alcohol testing, airbags, EBS, car

safety improvement and structural traffic changes resulting in speed

reduction. Intense sensitisation campaigns (fig. 1) have made the public

aware of the problem of traffic related trauma and may have contributed to

the reduction of traffic related mortality and morbidity. Recently, the

government made the reduction of traffic related mortality and morbidity

one of its main topics. They want to increase traffic control and - by


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augmenting the detecting chance and the penalties - reduce the driver

induced traffic risks.

The lack of drivers responsibility is one of the main causes of traffic related

mortality and morbidity. In 4168 out of 49065 accidents (i.e. 8.5%) in 2000,

ethanol intoxication was one of the contributing factors. When we look at

the accidents with at least one fatality or severely injured victim, we see that

in 949 out of 9346 (i.e. 10.2%) accident ethanol intoxication in one of the

drivers was recorded. Ethanol intoxication as a cause of an accident causing

fatality or severe injuries is time dependent. On week days it is only

recorded in 5.1%, on weekend days in 10.8%, on week nights in 18.5% and

on weekend nights even in 23.8%. These figures underestimate the situation

as in many fatal accidents no blood probe could be obtained. Apart from

ethanol intoxication, narcotic drug abuse plays an increasingly important

part in traffic accidents [15]. Surprisingly, the highest percentages of

ethanol intoxications in fatality or severely injury related accidents are not

seen in the younger age groups, but in the group 30-39 years. Even the

group 50-59 years scores as high as the group 25-29 years and higher than

in the group 18-25 years.(table 3)

Speeding with secondary loss of control is the cause of 642 out of 1356 (i.e.

47.3%) fatality related accidents in which the cause could be detected. Not

giving priority is the second most frequent cause in 16.8% of cases [14].


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Looking at the ascertained traffic infractions, we notice that speeding leads

with 346501 infractions followed by parking infractions (32236), not

wearing the safety belt (42033 infractions), ethanol intoxication (15030

infractions), neglecting traffic lights (14059 infractions) [14].

Discussion

Looking at the available data, one could be pleased with the Belgian

situation. Although the number of driven kilometres almost tripled since

1972, the number of traffic deaths halved. Of course this is not a bad

statistic. When looking over the borders of our country, statistics are

however not so positive anymore. In the year 1999, traffic related mortality

was 13.7 deaths pro 100000 citizens. Looking at our neighbours Germany

scored 9.5/100000, the Netherlands 6.9, Luxembourg 13.7 and France 14.4

[14].

Of course progression is made due to structural changes on car safety

(safety belt obligation, car safety, ABS, air bags, ) and on speed reducing-

safety augmenting structural changes (traffic islands, refuges, rotundas, ).

The influence of organisation of the pre-hospital care cannot be detected in

the available data yet.


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However, one cannot neglect the fact that reducing traffic related mortality

and morbidity has to be based on three pillars: reducing the accident risk,

reducing the impact forces and amelioration of the care for the victim.

Reducing the accident risk can be accomplished by sensitisation of the

driver resulting in decreased risk-behaviour. Beside this sensitisation one

should implement structural changes making traffic safer for all participants

(traffic islands, separated biking roads, rotundas, ) and augment

repression by intense controlling. This is in the first place a governmental

duty. Structural changes reducing impact forces and protection of all

participants in traffic are an industrial challenge. The medical part of the

challenge is to improve the care for the injured. A well-organised pre-

hospital care is crucial in this care for the injured. Although the initial goals

of structural organisation could not be reached, whether or not influenced by

lobbying groups, Belgium has a fairly good organisation of the pre-hospital

care. A slight reduction of the recognised emergency departments could

reduce costs and improve the experience through a broader exposure.

The problem of trauma care in Belgium is the total lack of coordinated intra-

hospital care. Too often ad hoc organisation, leading to unclear procedures

and loss of crucial time, has to be established. Many reports from all over

the world have documented the reduction in overall mortality, preventable

death and morbidity after installation of a regionalized and well-organized

trauma system [21, 22, 23, 24, 25, 26]. Unpublished data demonstrate the


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fact that trauma care in Belgium can also reach high standards of care for

the injured if in the setting of an organised Trauma Team, where trauma

dedicated surgeons work together with specialists in the emergency

medicine, intensive care and revalidation [16]. Standards comparable to

those reached in the centres participating in the American and British

MTOS (Major Trauma Outcome Study) studies [17, 18] and those reported

by the German DGU (Deutsche Gesellschaft fr Unfallchirurgie) [19].

Although trauma is the third leading cause of death after malignancies and

arteriosclerosis and even the leading cause of death in the population under

40 years of age, it remains the neglected disease [20]. Beside its high

mortality, it is responsible for a whether or not permanent loss of function in

an immense group of patients. Adequate trauma care can - as demonstrated

by many other countries - lead to a decrease in mortality and improved

outcome. It is no longer acceptable that inappropriate trauma care is

established because of lacking experience and/or means, because of

financial reasons (a too large spread of the offered pathology) or because of

a lack of interest for those institutions where all means are available (lack of

fashionable).

When the Belgian politicians want to halve mortality due to traffic accidents

by 2010, as they stated, Im afraid that sensitisation, repression, structural

changes and safer cars alone will come short. The implementation of a well-

organized trauma system, starting from excellent pre- hospital care and


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ending in excellent revalidation facilities, should be an integral part of this

policy. The coordination of such teams cannot be born in amateurism or ad

hoc interest, but should be supported by well-trained, experienced trauma

specialists (surgeons) working in close relation to the other intra-mural

cooperates (emergency specialists, ICU (Intensive Care Unit) specialists,

revalidation physicians, neurosurgeons, ) and to each other in a

regionalised and echelonised trauma system.

In my opinion, we should come to a European standard for trauma care,

where every inhabitant of the European community can get the same well-

organised care based on the best available experience within the community.

Mortality should no longer range between 21.1/100000/year (as in Portugal)

and 6.0/100000/year (as in the UK).


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Table 1: Evolution of the traffic related mortality/morbidity.

Year Deaths

30 days

Deaths 30 days +

severely injured

Victims (deaths 30

days + injured)

Motor vehicles (on

1st

August)

Vehicle Kilometres (in

milliard)

1972

1975

1980

1985

1990

1995

2000

3.101

2.346

2.396

1.801

1.976

1.449

1.470

26.711

21.735

22.325

18.533

19.455

14.166

11.317

106.538

84.478

84.700

76.315

88.160

71.754

69.431

2.732.677

3.136.909

3.753.745

3.970.866

4.594.058

5.136.342

5.735.034

32,69

38,01

47,96

53,64

70,28

80,26

90,04


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Table 2: Traffic related mortality in Europe (1999)

Country Number of deaths per 100.000 inhabitants

Belgium

Germany

France

Luxembourg

The Netherlands

United Kingdom

13.7

9.5

14.4

13.5

6.9

6.0

Source: IRTAD-International Road Traffic and Accident Database (OECD)


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Table 3: Alcohol intoxication in accidents with deaths/severely injured.

Age Number of drivers

involved

Number of drivers

involved under the

influence of alcohol

%

18-24

25-29

30-39

40-49

50-59

60-69

70+

2.287

1.453

2.337

1.676

987

597

537

170

118

216

145

79

22

12

7,4

8,1

9,2

8,7

8,0

3,7

2,2

Total 10.204 787 7,7


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Figures

Fig. 1: Example of a sensitisation campaign.


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References

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