INTERNATIONAL NURSING

THE PORTUGUESE EMERGENCY MEDICAL SYSTEM

Authors: José Miguel Padilha, PhD, MScN, RN, and Nelson Coimbra, MS, RN, Porto, Portugal
Section Editors: Pat Clutter, MEd, RN, CEN, FAEN, and Nancy Mannion Bonalumi, MS, RN, CEN, FAEN

ortugal, which was founded in 1143, is a small The Portuguese NHS is composed of groups of health

P southwest European country with a total of

35,556.15 square miles (roughly the size of the
state of Maine in the United States). It consists of a
centers based in the community, including local health
units and hospitals. Presently Portugal has 229 hospitals
(122 public and 107 private) with different levels of
continental portion that shares a land border with Spain specialization. 4 In 2012 Portugal had 433.1 physicians and
and a maritime border with the Atlantic Ocean, along with 699.3 nurses per 100,000 inhabitants. 5
2 archipelagos: the Azores and Madeira. Portugal has been a
member of the European Community since 1985 and has a
population of approximately 10,562,178 inhabitants Nursing in Portugal
(52.2% female and 47.8% male). Portugal is facing the
The first nursing references in Portugal date back to 1120.
progressive aging of its population. Presently 14.7% of the
At that time nursing care was provided by religious groups
population is aged 14 years or younger, 65.7% is between
and by other undifferentiated people. At the end of the 19th
15 and 64 years, and 19.6% is 65 years or older. The
century the first nurse training course was created. The first
average life expectancy at birth is 80 years (82.8 for women
union movement arose in the 1930s, and in 1950, the
and 76.9 for men) 1; the birth rate is 7.9%, the overall
regulation for the functioning of nursing schools was
mortality rate is 10.2%, and the infant mortality rate is
created, with nurse training becoming a 3-year program. In
2.9%. Figure 1 shows the main causes of death in Portugal.
1998, nursing education was integrated into the national
In 2010, Portugal’s death rate for traffic accidents was 7.8
education system, which allowed nurses to have academic
deaths/100,000, 2 and the death rate for work accidents was
training (a bachelor’s degree). In 1992, the first master’s
4.4 deaths/100,000. 1
degree in nursing became operational, and in 1999, nursing
In 2013, the Portuguese gross domestic product was
education became a 4-year program. In 1998 the Ordem
165,666,300 Euros. 1 The Portuguese health system
dos Enfermeiros (OE; Portuguese Order of Nurses) was
consists of the National Health System (NHS) with public
created. The OE is the competent authority and represents
financing, public and private subsystems, and health
nursing and midwifery graduates who practice in Portugal.
insurance. 3 The NHS is the main structure providing
It promotes the defense of the quality of nursing care
health care, and it ensures the right to universal access to
rendered to the population and develops, regulates,
health care for all citizens. In 2012, the cost of health care
and controls the practice of nursing and midwifery,
per inhabitant was 1486 Euros. In 2012, 9.2% of the gross
guaranteeing that ethical and professional deontology rules
domestic product was invested in health care, with 62.64%
are respected.
of the total cost of health care guaranteed and the remaining
An honors degree is required to practice nursing in
37.35% guaranteed by the private sector. Of the private
Portugal. The honors degree in nursing requires 4 years of
sector’s investment in health care, 84.7% is guaranteed
study and a total of 3941 hours (240 ECTS—European
directly by the families, 13.6% by health insurance, and the
Credit Transfer System) consisting of a theoretical and an
remaining by nonprofit organizations. 1
internship component.
After obtaining an honors degree, nurses can comple-
ment their training in the prehospital emergency area with
José Miguel Padilha is Professor, Porto Nursing School, Porto, Portugal. professional education provided by the National Institute of
Nelson Coimbra is Medical Surgical Specialist Nurse, Centro Hospitalar do Medical Emergency (Instituto Nacional de Emergência
Porto and Professor, Santa Maria Nursing School, Porto, Portugal. Médica; INEM). This training is professional in nature. In
For correspondence, write: José Miguel Padilha, PhD, MScN, RN, Porto Portugal there is no specialization in emergency nursing,
Nursing School, Street Dr. António Bernardino de Almeida 4200-072 Porto, given the nature and organizational conceptual matrix
Portugal; E-mail: miguelpadilha@esenf.pt.
adopted by the nursing discipline.
J Emerg Nurs 2015;41:255-9.
0099-1767
At the end of 2013, 65,872 nurses (81.7% women and
Copyright © 2015 Emergency Nurses Association. Published by Elsevier.
18.3% men) were enrolled in the OE. Of these enrollees,
All rights reserved. 19.9% (n = 13,087) stated a nursing specialty. Figure 2
http://dx.doi.org/10.1016/j.jen.2015.02.007 illustrates the distribution of Portuguese nurses by specialty.

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INTERNATIONAL NURSING/Padilha and Coimbra

FIGURE 2
Distribution of Portuguese nurses by specialty. Data from Ordem dos Enfermeiros,
FIGURE 1
2014. 6
Main causes of death in Portugal in 2012.

Postgraduate nursing education was instituted in Portugal or contributions relating to life insurance contracts, as well
in 2003. 6 as disease, accident, and vehicle insurance.
Since 2001 Portuguese nurses have had the opportu- In 1987 the Center for Counseling of Emergency
nity to complete their academic training with a doctoral Patients (Centro de Orientação de Doentes Urgentes;
degree from Portuguese universities. Portugal has a ratio of CODU) was founded in Lisbon as a guiding center,
6.2 nurses per 1000 inhabitants, which is lower than the regulator, and coordinator of medical assistance, which
average ratio of 8.6 in countries of the Organization for allowed the evolution toward telephone medical triage.
Economic Cooperation and Development. 6 Currently 4 CODUs operate 24 hours a day. Their services
are provided by physicians and technical operators of
emergency telecommunications with specific training to
The History of Prehospital Emergency Services perform the service, including screening, counseling, and
in Portugal selection and deployment of rescue resources. The CODU
coordinates and manages the set of rescue resources (ie,
Prehospital emergency care started in 1965 with imple- ambulances, medical emergency and resuscitation vehicles,
mentation of the national emergency number 115. emergency motorcycles, interhospital pediatric transport,
Currently 112 is the accepted number in European and emergency helicopters). In 1987, the ambulance service
countries. This emergency number was used in the first
phase to help accident victims on public roads in the
Portuguese capital, and response was ensured by the police.
In 1971, the National Ambulance Service (Serviço
Nacional de Ambulâncias) was created and equipped with
medical ambulances, sanitary equipment, and telecommu-
nications. The ambulances were operated by the police in
some major Portuguese cities; in the remaining areas,
firefighter corporations operated the ambulances.
In 1981 INEM was created as the coordinating
organism of medical emergency activities in Portugal. The
mission of INEM is to define, organize, coordinate,
participate in, and evaluate the activities and functioning
of the Integrated System of Medical Emergency (Sistema
Integrado de Emergência Médica; SIEM) to ensure prompt
and proper care in medical emergencies in Portugal. 7 FIGURE 3
INEM is primarily financed by charging 2% on premiums Emergency helicopter with hospital in background.

256 JOURNAL OF EMERGENCY NURSING VOLUME 41 • ISSUE 3 May 2015


FIGURE 4
Author Nelson Coimbra, MS, RN.
for interhospital pediatric transport (Transporte Inter-
hospitalar Pediátrico; TIP) was created. TIP has a team
consisting of a physician, a nurse with emergency training,
and an emergency technician whose mission is the rapid
deployment of critical patients with an urgent pediatric
transport team, clinical stabilization of newborns and/or
seriously ill children, and accompanied transport to the
proper health unit considering the patient’s clinical status.
In 1989, the first Medical Emergency and Resuscita-
tion Vehicle (Viatura Médica de Emergência e Reanimação;
VMER) emerged, which permitted a qualitative improve-
ment in care provision in prehospital emergencies. The
VMER is a prehospital intervention vehicle that provides
quick transport of a medical team, consisting of a physician
and a nurse with emergency training along with advanced
FIGURE 5
Medical emergency motorcycle.
May 2015 VOLUME 41 • ISSUE 3
Padilha and Coimbra/INTERNATIONAL NURSING
life support equipment, directly to the location where the
victim is found. The VMER is operated directly under the
auspices of CODU and has a hospital base, functioning as
an extension of the emergency service to the community.
In 1996 the Catastrophe Intervention Vehicle (Viaturas
de Intervenção em Catástrofe) emerged and is used in
situations with multiple victims. This vehicle transports
various advanced life support materials, allowing assembly of
an advanced medical post that includes a telecommunication
cell, thus permitting the creation of a communication network.
In 1997 the Medical Emergency Helicopter Service was
initiated. The mission of this Service is the rapid transport
of a medical team (physician and nurse) with emergency
training to the location of the incident, with the objective of
prehospital stabilization and monitoring, transport to the
hospital unit, and support in the secondary treatment and
transport of critical patients (see Figures 3 and 4).
In 2004 motorcycles became one of the means of
transport available to the INEM in an urban context with a
great population density. This vehicle is equipped with basic
rescue materials and an automatic external defibrillator and
is staffed by an emergency technician (see Figure 5).
In 2007, Immediate Life Support (Suporte Imediato de
Vida; SIV) ambulances were created. SIVs have the mission
of guaranteeing differentiated health care, such as resusci-
tation procedures. The crew consists of a nurse with
emergency training and an emergency technician, and their
objective is to optimize the care provided in the prehospital
environment. In the SIV the nurse acts on the basis of
protocols instituted by the INEM, and the protocols are
operationally coordinated by emergency central (CODU).
In Portugal, emergency technicians have a 12-year basic
education followed by 210 hours of training. The
emergency technician is capable of basic life support, basic
wound management, administration of oxygen, patient
extrication, patient transfer, spine and fracture immobiliza-
tion, and uncomplicated obstetric delivery. 8
How the SIEM Functions
Functioning of the SIEM begins when someone calls 112
(the European emergency number). 9 All 112 calls are
answered by the police in the emergency call centers. In
health-related situations, the call is forwarded to INEM’s
CODU. At the CODU a medical emergency telephone
triage is performed followed by a definition of priorities,
medical counseling, activation of emergency resources, and,
when deemed necessary, the guiding of patients to the
emergency service network.
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INTERNATIONAL NURSING/Padilha and Coimbra

FIGURE 6
Immediate life support vehicle, medical emergency ambulance, and medical emergency and resuscitation car.

To ensure speed and efficiency in the multiple
situations in the area of medical emergency, the INEM
has nonmedicalized resources 10 (operated by emergency
technicians) and medicalized resources (with physician and/
or nurse with emergency training). Nonmedicalized re-
sources include 331 medical emergency ambulances (ambu-
lâncias de emergência médica) and 8 medical emergency
motorcycles (motas de emergência médica). Medicalized
resources include 39 immediate life support ambulances
(SIVs), 42 medical emergency and resuscitation vehicles
(VMERs), 6 medical emergency helicopters, and 4 TIP
ambulances 11 (see Figure 6).
The Emergency Medicine Model in Portugal
The Portuguese medical emergency model is a Franco-German
model that is based on highly differentiated health professionals
who go to the scene of the incident to start treatment as early as
possible, stabilize the victim, and, if necessary, proceed to the
best equipped healthcare facility. The success of the emergency
medicine network has as its central element its articulation,
integration, and guarantee of continuous care, which implies
having health professionals with various levels of differentiation
and training in the area of emergency medicine (ie, physicians,
nurses, and emergency technicians).

TABLE
Professional training for Portuguese nurses in the area of prehospital emergency medicine
Mean Modules Theory Internship
Medical emergency and Medical emergencies; trauma emergencies; 122 hours 35 hours
resuscitation vehicle pediatric and obstetric emergencies;
advanced life support; critical patient transport and
triage and catastrophe;
victim extraction/immobilization techniques; emer-
gency driving
Immediate life support Medical emergencies; trauma emergencies; 80 hours 56 hours
ambulance pediatric and obstetric emergencies;
advanced life support; critical patient transport and
triage and catastrophe;
victim extraction/immobilization techniques
Interhospital pediatric Nursing specialty in infant and pediatric health 1022 hours
transport
Medical emergency helicopter All modules for medical emergency and resuscitation 8 hours
vehicle plus flight physiology and heliport safety

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Prehospital nursing in Portugal is performed in an
organized fashion in the INEM’s structure. Nurses operate
specifically in the context of medical emergency and
resuscitation vehicles, in the immediate life support
ambulances, in the medical emergency helicopter service,
and in the interhospital pediatric transport. Table outlines
the training of the Portuguese nurses to access professional
practice in the area of prehospital emergency care.
REFERENCES
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Submissions to this column are encouraged and may be sent to
Pat Clutter, MEd, RN, CEN, FAEN
prclutter@gmail.com
or
Nancy Mannion Bonalumi, MS, RN, CEN, FAEN
nbonalumi@comcast.net
WWW.JENONLINE.ORG 259