International EMS system Design: Sweden
Sweden is situated in the northern part of Europe on the Scandinavian Peninsula, borders with Norway and Finland and has a bridge-tunnel connection with Denmark. It is the third largest country in the European Union by area (450,295 square kilometres), and has a population of 9.4 million inhabitants. The population is concentrated in the southern half of the country and there are 20.6 inhabitants per square kilometre.(1) The country is divided into 20 county councils; political entities elected by the county electorate. The county council’s main responsibilities lie within the health-care system. The county council has the overall responsibility for the ambulance service and the service may be provided as part of the public sector (approximately 80 per cent) or by private entrepreneurs (approximately 20 per cent). The trend is that politically right-winged county councils use private entrepreneurs to a greater extent than left-winged.
The modern ambulance service has its roots in the 1950s and was before that regarded as a pure transport organization. A new comprehensive standard for ambulances was established in the 1960s which ensured all ambulances be equipped with first aid material, equipment for prehospital delivery, mechanical ventilation and oxygen therapy, etc. In addition, a three-week course was introduced for the personnel.
The organization was often integrated with the fire brigade, and many ambulance workers worked alternately as firefighters (this tradition lived until the beginning of the 21st century). During the 1970s and 1980s, anesthesiologists, who had a supervisory liability to the organization, contributed to the development of the ambulance service.
More interventions were introduced, including delegation to give drugs, and rapid response units with nurse anesthetists became part of the prehospital organization. The educational requirements were initially raised from seven weeks to 20 weeks, and later, 40 weeks of prehospital training to become an ambulance caregiver. The pre-requirement to be enrolled was assistant nurse.
It was in this era the term “ambulance driver” was changed to “ambulance caregiver” (freely translated from Swedish). In the 1990s there was volition to accomplish the same requirements regarding safety, quality and competence in the prehospital arena as is offered intra-hospital. During this time there was a vociferous debate if ambulance caregivers should be a regulated occupation or not. However, the Swedish National Board of Health and Welfare (the regulatory organ for Swedish health care) declined this wish, and laid ground for registered nurses to be the backbone of all medical interventions in prehospital care. From 2005, all ambulances where the crew is expected to perform more advanced medical treatments have at a very minimum one registered nurse and one ambulance caregiver present.
Levels and education
Today Sweden has about 4,000 persons working clinically in the ambulance service.(2) There are two medicolegal levels; registered professions (in Sweden this is called license to practice) and non-registered professions. Ambulance caregivers (ambulanssjukvårdare) are non-registered. The registered professions are registered nurses, registered nurse specialists and in rare cases, physicians.
Before 2005, the pathway to become an ambulance caregiver was to have an education in assistant nursing, working experience from emergency care and a post-graduate course in ambulance care. The length of the post-graduate course was 40 weeks (older curriculums were seven and 20 weeks.) In 2005, the National Board of Health and Welfare withdrew the privilege for non-registered professions to give drugs. In doing so, most of the educational programs for ambulance caregivers were canceled and the title has gone from being an educational title to an occupational title. Most ambulance caregivers have long experience and the few junior ambulance caregivers that start today are often nurses under training. During the change-over, most ambulance organizations intended to employ 30 per cent ambulance caregivers and 70 per cent nurses. However, the reality is that nurses make up a larger proportion than this, and the future for ambulance caregivers is uncertain.
The minimum requirement for administrating drugs is registered nurse. All Swedish ambulances have at the very minimum one registered nurse in the crew (some patient transport organizations are excluded). The education to become a registered nurse is three years of university studies, leading to a bachelor’s degree in science (nursing).
Registered nurse specialist
Most organizations have extended the requirements and it is common that at least one of two in the crew is a nurse specialist in emergency nursing. The pre-requirement is one year of work experience as a registered nurse and one year post-graduate studies in emergency nursing. The degree may be issued in prehospital nursing, intensive care nursing or anesthetic nursing. The studies are part of a master’s degree.
There are only a few cities where physicians are working clinically. These are usually anesthesiologists or emergency medicine specialists/residents.
All ambulance organizations have a group of medical directors who audit and assure quality of the organization, as well as ensure the individual ambulance staff meets the expected clinical standard. There is mandatory in-job training, usually 50 to 100 hours per year, and re-credentialing is done annually.
Scope of practice
All ambulance caregivers have skills in basic life support (BLS). They are delegated to do peripheral venous cannulation, and in some areas, to use laryngeal masks and intubate cardiac arrest patients. Priority 2 and 3 missions may be handled by the ambulance caregiver if the condition of the patient allows and if no medical treatment is expected. However, the main responsibilities for ambulance caregivers lies with technical apparatuses, vehicle maintenance and radio communications. On major accidents, the ambulance caregiver in the first arriving ambulance will be the incident commander. This requires skills in leadership and knowledge of the pre-determined major accident plan.
Registered nurse and registered nurse specialist
A national association (SLAS) consisting of supervisory physicians is cooperating to create and have up-to-date clinical protocols for the ambulance services.(3) There are however, local differences to these. The scope of practice is generally similar for a registered nurse and a nurse specialist (therefore, referred to as “nurse” from here on). Nurses work autonomously with assessment, evaluation and treatment based on protocols, guidelines and regional medical directives. A wide range of drugs can be administrated prehospital. Manual defibrillation and reduction of some types of fractures and dislocations are examples of medical procedures that can be done by the nurse. A physician may issue a standing delegation for procedures that lie outside formal education for some nurses. This might include intubation, intraossious access or needle thoracostomy. For specific situations, the physician may authorize the nurse to write a radiology referral. In some parts of Sweden, nurse specialists in anesthetics have extended authorities to give hypnotics and muscle relaxants. The lack of ambulance caregivers means nurses also need to have skills in ambulance driving, technical apparatuses, vehicle maintenance, radio communications, etc.
Innovations in the ambulance service
Most ambulance organizations have some form of tool for triage, and the most prevailing is Medical Emergency Triage and Treatment System (METTS). The same protocol is used both prehospital and in the emergency department (ED). It is a triage scoring system that includes both symptoms and vital signs and categorizes patients in four categories depending on the severity of the patient’s condition. The categories indicate how fast the patient needs medical attention when arriving at the hospital, but also which laboratory tests that needs to be sampled in the ED. Category Red is classified as the most severe and the patient is in need of immediate medical attention. Category Green is the least serious, and denotes waiting time has no impact on patient’s condition. In between there are Orange and Yellow. The primary triage that traditionally was done by nurses in the ED has moved out to nurses in the ambulances.
Designated patient groups that do not necessary need care in the ED can be bypassed for faster handling. This can be a patient that needs interventions quickly (e.g. AMI patient that needs PCI) or a patient that traditionally after an assessment stays in the ED solely waiting to be admitted to a ward (e.g. elderly patient with co-morbidity that needs antibiotics or fluids for a couple of days). When the ambulance nurse identifies a patient that might be a suitable candidate for a certain fast track, a protocol with inclusion and exclusion criteria is filled out. If the patient is included, the nurse is obligated to follow a task-orientated protocol. This might include putting on an identification tag, let the patient change to a hospital gown, collect blood samples, cannulation, etc. These are tasks that in other cases are done in the ED. It also includes specific medical treatments. The most common fast tracks are described below.
Acute Myocardial Infarction
An ECG is collected and sent to a cardiologist on all patients with chest pain and ST-evaluation or LBBB. The cardiologist decides if the patient should go to the ED, directly to a cardiac intensive care unit or directly to an operating theatre for PCI (in some distant areas the cardiologist may delegate to administrate thrombolysis). The task-orientated protocol usually includes specific drug treatment and monitoring.
Elderly persons complaining of hip pain after a low-energy trauma are directly transported to radiology for an X-ray. If a fracture is confirmed, the patient is put in a hospital bed and the ambulance personnel transport the patient to an orthopaedic ward. The task-orientated protocol includes writing a referral for X-ray; put on an identification tag; let the patient change to a hospital gown; collect blood samples and ECG needed for surgery; and consultation with the bed coordinator in the hospital. It also gives instructions that the patient should be given adequate pain treatment. A Swedish study showed the additional time the ambulance is spending with the patient is 30 minutes, but by doing so, time between the scene of the accident and the arrival at the orthopaedic ward is reduced by approximately four hours. It also claims that post-operative complications, specifically mental confusion and pain are significantly reduced when the patient is fast tracked.(6)
Patients with suspected stroke can be fast tracked in two ways. If the patient meets the inclusion criteria for thrombolysis, the ambulance nurse consults with the neurologist who arranges for a CT-scan. The patient is then transported directly to radiology. If the patient is excluded but symptomatic, the patient is transported to a neurology ward.
Elderly persons without life-threatening conditions, but are in need of hospitalization can – after consultation with a geriatrician – be admitted to a ward without stopping at the ED.
Patients with outpatient care needs are usually not in need of ambulance transportation. However, significant portions of all ambulance missions are patients from this category. If the circumstance requires the patient to be transported in an ambulance, the nurse has the ability make the decision to transport the patient to an outpatient care unit instead of the ED.
The ambulance service in Sweden has taken a different path from many other countries by not using paramedics, but instead nurses, as primary professionals in the prehospital domain. It has been shown to result in several benefits, such as closer collaboration with the intra-hospital units to develop fast tracks, and unburdening some of the workload from the staff in the emergency department. In the future, there will most certainly be more evolution in this area, and also even more advanced treatments available for the critical ill patient than is offered today.
5. http://www.skane.se/sv/Webbplatser/SUS/Skanes-universitetssjukhus-Lund/Vard/Verksamheter/Akutdivisionen/Region-Skanes-Prehospitala-Centrum/For-vardgivare/Guidelines-och-vardprogram/Vardprogram/Larsson G, Holgers KM. Injury. 201;42(11):1257-61.
6. Fast-track care for patients with suspected hip fracture.
About the Author
Andreas Bom is a registered nurse specialist from Sweden. He has a bachelor’s degree in nursing from Kalmar University College, and a post-graduate diploma in emergency nursing, anesthetics from Mälardalen University. Bom has worked as an ambulance nurse and a nurse anesthetist since 2007 in Trelleborg and Malmö. He currently works as a researcher at University of Sydney in Sydney, Australia, but will move back to Sweden and start work clinically within a couple of months.