Measuring EMS quality in the Nordic countries
Editor’s note: Although we usually present a single piece of research in this column, this month we instead present an important article on efforts to benchmark EMS quality in Nordic countries-Norway, Sweden, Finland, Denmark and Iceland.
Prehospital services are in transition in the Nordic countries, with similar trends worldwide. Increase in population, longer life expectancy and a rapidly growing elderly population increase the need for healthcare, including EMS and out-of-hospital care.
The percentage of growth in the number of calls to Norway’s emergency medical number, 1-1-3, has been exceeding the population increase.
Healthcare services are increasingly being transferred out of the hospital setting. The ability to diagnose and treat a patient with a complex health condition in the prehospital setting demands improved qualifications for prehospital personnel.
This improvement could prevent unnecessary hospitalization and improve the patient’s quality of care.
EMS systems provide important benefits to the public, including providing immediate medical care in response to individual health emergencies, and responding to mass casualty incidents and disasters that threaten the health and safety of the public.
Despite its relevance to healthcare access and medical outcomes, EMS hasn’t received the same recognition and support from policymakers as other parts of specialized healthcare or hospital services. However, there have been shifts in policy the last couple of years.
In Norway, a white paper was put forward pointing out how to strengthen EMS system design, leadership and education.1 Subsequently, regulation reform was put through parliament, ensuring and supporting the tasks it laid out.2
In Norway, a white paper was put forward pointing out how to strengthen EMS system design, leadership & education.
Similar changes in EMS policy have occurred in other Nordic countries, where EMS agencies have a limited tradition in measuring health effects. There’s scarce documentation on survival, limited scientific publications and few quality indicators except for those that relate to response time.
A national working group comprised of EMS personnel, patient registry and the Norwegian government began developing quality indicators for prehospital services in 2015.
In 2016, four new quality indicators were developed and introduced online.
Dispatch Response Time
The first quality indicator involves emergency medical dispatch (EMD) response time. In Norway, EMD is the first point of contact for emergency medical calls, and nurses answer all calls to the 1-1-3 emergency medical number.
To solidify the public’s feeling of safety, it’s important that the EMD answers emergency calls rapidly to secure quick medical treatment to the patients. In many cases, the time from incident occurrence until the patient is treated is of crucial importance for patient survival and EMS service efficiency.
The Norwegian government now demands that 90% of emergency medical calls be answered within 10 seconds by EMD. Data now shows that 87% of calls are being answered within this timeframe. In spite of the fact that the 90% quality indicator hasn’t yet been reached, EMD responsiveness has improved during the period of measuring.
EMS Response Time
This quality indicator measures the time from call receipt by EMD until the time an ambulance unit is on scene for acute missions. Because of differences in Norway’s geography and settlement patterns, the goals for urban and rural areas are 12 and 25 minutes, respectively.
The time from when a potentially serious incident occurs until the patient has received necessary medical treatment is significant to avoid unnecessary death, loss of life and level of functioning for the patient.
Acute medical conditions such as cardiac arrest, stroke, acute heart attack and serious trauma require a quick response to save lives and better the patient’s chances to maintain their level of functioning. For instance, it’s estimated that the chance of surviving an out-of-hospital cardiac arrest is reduced by 10% per each minute the use of a defibrillator is delayed.3
The latest results show that Norway’s EMS response in urban areas is 17 minutes-still five minutes away from the 12-minute goal. In rural areas of the country, EMS response time is 32 minutes, which is 7 minutes later than the 25-minute target.
Making these results public has resulted in increased focus on EMS as well as increased discussion and debate in both the Norwegian health service organizations and the media.
Though EMS hasn’t yet met their goals, the trend is promising, with response times decreasing for high-acuity calls in both urban and rural areas.
We’ve developed quality indicators that are telling us more about the quality of care and outcome for patients treated by EMS. These quality indicators highlight just one part of a complex course of patient treatment, and it’s important to not overemphasize the result of a single indicator.
In order to have more data available to measure and evaluate quality indicators, we’re working on establishing quality medical registries of prehospital services and implementing national electronic healthcare patient records for our ambulance services. Fortunately, the Norwegian Cardiac Arrest Registry is already a data provider to the national quality indicators for this patient group.
Bystander CPR & ROSC
There are two quality indicators for cardiac arrest: bystander CPR and return of spontaneous circulation (ROSC) to hospital.
The first indicator measures the number of sudden and unexpected out-of-hospital cardiac arrests where a bystander has started CPR before EMS arrives on scene.
In Norway, as well as in the rest of the world, the public plays an important role in the chain of survival. Minutes count when cardiac arrest occurs and bystanders must recognize the situation and call the emergency number for CPR guidance. The immediate start of CPR by bystanders has therefore been made a top priority in Norway and all the Nordic countries.
In Norway, eight out of 10 patients with cardiac arrest (82.6%) now receive bystander CPR before EMS arrival.
The second indicator for cardiac arrest is ROSC to hospital, which measures how many patients with sudden unexpected cardiac arrest regain a heart rhythm before arriving at a hospital or have regained a heart rhythm for at least 20 minutes. Results for this indicator are dependent on the efforts, interaction and cooperation between the public and all the actors in the emergency medical chain.
In Norway, 30% of cardiac arrest patients are currently resuscitated successfully.
The Nordic collaboration on benchmarking EMS began in 2014, with a goal to develop comparable data to support improvement of patient safety and quality in by 2018. The work is done in three working groups: 1) response time; 2) assess, treat and release; and 3) cardiac arrest, ST-elevation myocardial infarction (STEMI) and stroke.
The group has defined common time stamps and intervals for EMS, as well as a common data structure for data collection. A total of 29 common quality indicators have been defined, and final quality indicators will be chosen from this list. (See Table 1.)
The cooperation has been fruitful and supportive in the national processes of developing EMS in each country.
Because we’re in the process regarding choosing a small number of quality indicators for benchmarking out of the preliminary list, we’re interested in your experiences, ideas and comments. Please provide feedback to Janne K. Kjøllesdal, who can be contacted at
Table 1: Preliminary list of EMS quality indicators proposed for Nordic countries
1. Committee on Acute Affairs. (Dec. 4, 2015.) First and foremost: A comprehensive system for dealing with acute diseases and injuries outside hospitals. Norway Ministry of Health and Care Services. Retrieved Oct. 30, 2017, from www.regjeringen.no/no/dokumenter/nou-2015-17/id2465765.
2. Regulations on requirements and organization of municipal emergency services, ambulance services, emergency medical services, etc. (emergency medicine regulations). (March 20, 2015.) Norway Ministry of Health and Care Services. Retrieved Oct. 30, 2017, from www.regjeringen.no/no/dokumenter/id2401617.
3. Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council guidelines for resuscitation 2010 section 1: Executive summary. Resuscitation. 2010;81(10):1219-1276.