Denmark’s small population (5.75 million) and land size (16,500 sq. mi., about the size of Maryland) might be one of the reasons its nationalized EMS system can focus on collaboration, high performance, and consistency. Couple that with a National Board of Health willing to innovate and recognize the unique skill sets of its EMS providers, and you get some notable results. It is an EMS system others in the developed world might consider emulating.
Make no mistake: EMS in Denmark faces many of the same challenges of other developed countries. There is an aging population, increasing calls for nonemergent needs, challenges of rural environments, struggles with recruitment and retention, and even a debate similar to America's about whether to require college degrees.
EMS in the Capital
Copenhagen EMS, the system in the capital region (where 1.8 million people reside), receives about 130,000 calls a year to its 1-1-2 emergency number. The EMS system is split into five regions countrywide, and all EMS services are free to Denmark’s citizens as part of its public healthcare system.
In Copenhagen EMS calls are responded to by both paramedics and nurses working for the Region Hovedstadens Akutberedskab (roughly EMS in the Capital Region of Denmark). EMS Copenhagen also runs physician-staffed chase cars, interfacility acute and nonacute transfers, a prehospital psychiatric critical care unit, and an ambulance that addresses social issues. Nationally four helicopters provide HEMS, and these can be dispatched by any of the EMS organizations in Denmark.
On a typical day EMS Copenhagen staffs 55 ambulances. Some are active for 24 hours, and others run for differing peak periods. Half of these ambulances are staffed by a paramedic and EMT-equivalent, or ambulancebehandler, while the rest run with an ambulancebehandler and an assistant.
Innovations Improve Survival
Much of the progress of EMS Copenhagen began in 2008, when the National Board of Health commissioned a 10-year plan to improve health services throughout Denmark. As part of that plan, EMS Copenhagen CEO Freddy Lippert, MD, was instrumental in working to improve patient care.
“We wanted to focus on putting the patient at the center of care,” Lippert says. He cites many new solutions proposed to accomplish the task, including better communications, better triage of 1-1-2 calls, and secondary triage. Prior to this plan the police department were the sole call-takers of 1-1-2 calls, but as of 2011 all emergency and nonemergency calls are handled by one emergency medical dispatch center.
EMS Copenhagen prides itself on prehospital innovations, such as point-of-care troponin testing, video-aided telephone CPR, and the use of artificial intelligence (AI) in call-taking.
Video-aided telephone CPR procedures are still in the early stages: When a 1-1-2 call comes in that sounds like a cardiac arrest, call-takers like nurse Anne Marie Esbensen send the caller a text message that contains a hyperlink. When they click it Esbensen can view the scene through the caller’s cell phone camera, live and in real time.
This is a big change to the standard practice of most call-takers, and Lippert acknowledges more training is needed to figure out how best to use video to improve triage and decision-making.
Esbensen, for her part, is a convert to the ability to “see” a scene that she previously could only hear. “I’m trying to make sure the CPR instructions are clear,” she says. “The video can really help with that—to make sure they’re on the floor, pushing as instructed.”
As a part of its push to improve survival from SCA, EMS Copenhagen has also implemented tactics like AI that help call-takers better identify cardiac arrests. In a recent trial the AI successfully identified 90% of cardiac arrests over the phone.
Another initiative to train citizens in CPR has increased the rate of bystander CPR to 70%, up from around 20% 15 years ago. In the first year of using the Heartrunner app, 25,000 citizens registered to volunteer, and 6,500 have been involved in over 800 resuscitation attempts. In addition, EMS Copenhagen keeps AED locations continually updated on a real-time map call-takers can use to direct helpers to the nearest device. As of September 2019, approximately 20,000 AEDs have been registered across the nation.
Focus on Primary Care
What isn’t the same as many other developed nations’ EMS systems is Denmark’s focus on primary care and the integration of its call centers into this focus. By establishing a nonemergency number, 1-8-1-3, EMS Copenhagen has seen a more appropriate usage of medical services.
The emergency dispatch center in Copenhagen answers the 1-8-1-3 line, established in 2014, 24 hours a day, seven days a week. The call-takers are nurses and physicians working in the same call center as the 1-1-2 call-takers and dispatchers. Citizens in Copenhagen are well-versed in using this medical help line, and EMS Copenhagen has seen its popularity grow every year, with a million calls received annually.
Callers to 1-8-1-3 are helped to secure an ED “appointment” using EMS Copenhagen’s ability to view current ED capacity. The appointment is sent via text message to the patient. The collaborative nature of Copenhagen’s PSAP also allows for call transfers: 1-8-1-3 callers who actually need an ambulance are transferred with a click of a button, and 1-1-2 callers can also easily be transferred to 1-8-1-3 nurses.
EMS Copenhagen also conducts research projects, from the way calls to a PSAP are handled to the collaboration that happens with the rest of the healthcare system. Lippert and his colleagues have published in the last three years an impressive 50 articles regarding EMS research in various journals.
Lippert and his team ultimately strive to achieve the highest level of evidence-based medicine for Denmark’s EMS systems. “We want to do our part to make progress in healthcare,” says Lippert.
Hilary Gates, MAEd, NRP, is the senior editorial and program director for EMS World. She is a volunteer paramedic in Alexandria, Va., and teaches in the School of Education at American University in Washington, D.C. Gates has experience as a community paramedic, EMS educator, symposium presenter, and quality improvement trainer.