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86 cities Up to 500 km away from
a microregion headquarters
8 microregions
Area: 122,176 Km²(São Paulo: 1,523 Km²)
Population: 1,558,610(São Paulo: 10,990,249 inhabitants)
Population density: 12.6 inhab./km²(São Paulo: 7,216 inhabitants/km²)
Case StudyEmergency/Urgent Care Network
Northern Minas Gerais Macroregion
Indicator:
Years of Life Lost (YLL) > 1 year
Indicator:
Years of Life Lost (YLL) > 1 year
The leading causes of YLL among the population over 1 year of age are external causes and cardiovascular disease, which together account for more than 46% of this indicator.The leading causes of YLL among the population over 1 year of age are external causes and cardiovascular disease, which together account for more than 46% of this indicator.
YLL Rate > 1 yearYLL Rate > 1 year
External causesExternal causes
Cardiovascular diseaseCardiovascular disease
NeoplasmsNeoplasms Other diseases of the circulatory system
Other diseases of the circulatory system
Source: SIM/DATASUSSource: SIM/DATASUS
Diseases of the respiratory tractDiseases of the respiratory tract
Infectious/parasitic diseaseInfectious/parasitic disease
OthersOthersDiabetes mellitusDiabetes mellitusDiseases of the digestive tractDiseases of the digestive tract
10 Leading causes of years of life lost (YLL)in Minas Gerais, 2004-2006
DISEASE
YLL (thousands
)%
% (cumulati
ve)Rate
Ischemic heart disease 158 9.2 9.2 8.2
Cerebrovascular disease 144 8.4 17.6 7.5
Acts of violence 111 6.5 24.1 5.8
Traffic accidents 86 5.0 29.1 4.5
Lower respiratory tract infections
68 4.0 33.0 3.5
Hypertension 63 3.7 36.7 3.3
Diabetes mellitus 59 3.5 40.2 3.1
Asphyxiation/birth injuries 57 3.3 43.5 3.0
Cirrhosis of the liver 56 3.3 46.8 2.9
Inflammatory heart disease 43 2.5 49.3 2.2
EMERGENCY CARE: A Worldwide crisis
No coordination among service delivery points Excessive emergency room (first-aid) demand Difficulties in admitting patients for hospitalization Ambulances turned away Fragmented and disorganized transport Lack of specialized care Emergency rooms overburdened treating low-risk
patients System unprepared for major emergencies/increased
demand
Hospital-Based Emergency Care: At the Breaking Point http:/www.nap.edu/catalog/11621.html
International recommendations for alleviating emergency/urgent care network problems
Need for restructuring the network Consolidate coordination and command within a single
authority Need for regionalization of network services Compartmentalize services (concentration x dispersion),
e.g., comprehensive trauma care model Develop a “common terminology” (protocols and
guidelines) Encourage collective accountability Network management: use indicators that evaluate the
performance of both the services and the network (e.g., mortality due to major trauma within the first 24 hours)
Source: Hospital-Based Emergency Care at braking point
Institute of Medicine of the national academies - 2007
Objective of the emergency/urgent care services network
Take the patient to the nearest hospital
1. Correctly direct the patient…
2. … to the appropriate level of care
3. …that can provide the most effective treatment
4. …as fast as possible.
Core elements of the project proposed by the Minas Gerais Government
Create an optimal emergency/urgent care network based on the regionalization of services and adopt a “common terminology” for service delivery points, using a new management and financing model
Develop a system of macroregions
Distribute services based on economies of scale, availability, and access (time is most important in emergency care services)
In each microregion, 90% of the population must have access to network points of service located no more than 1 hour away (fixed facilities or mobile points of service)
The network’s guidelines (communication) determines the structure and communication among the points of service, and among points of operational and logistical support
CORE ELEMENTS OF HEALTH CARE NETWORKS
POPULATION (determined by geographical area) HEALTH CARE SERVICE POINTS (network levels) SUPPORT SYSTEMS (diagnostic and pharmaceutical)
LOGISTICAL SYSTEMS (expand prehospital screening for all regions)
OVERSIGHT (creation of supra-municipal structure/city consortiums)
HEALTH CARE MODEL (stratification of risk)
Source: Mendes (As redes de atenção à saúde 2009)
Economies of scaleAvailability of resourcesQuality
Access
LEVELS OF CARE
PRIMARY CARECall centersHealth posts (unidade basica de saúde – UBS)Charity or small-scale hospitals (hospitais filantrópicos e de pequeno porte [HF/HPP]). Local
small-scale hospitals perform a vital role within the network when access to higher-complexity services are located more than one hour away.
MEDIUM COMPLEXITYUrgent Care Units (Unidades de Pronto Atendimento – UPA)Microregional hospitals – these must be accessible to at least 100,000 inhabitants, some of
which should provide care for more complex traumas or stabilize such patientsEmergency Mobile Care Unit (Serviço de Atendimento Móvel de Urgência – SAMU)
TERTIARY LEVELMacroregional hospitals with specialized services in line with preestablished parameters
Trauma Referral Hospitals – must be located within access to at least 1 million inhabitants Hospital Referral/ CV; 400mil pop.
Rehabilitation Hospitals SAMU Health posts or UBS are the local care centers
Microregional/macroregional hospitals (former: more complex trauma)
Manchester Protocol for Emergency & Urgent Care:A “Common Terminology”
Classification of risk Single set of guidelines Manchester Protocol for Emergency & Urgent Care Identification of internal and external flows Accountability NUMBER NAME COLOR TIME TARGET
1 Emergency Red 0
2 Very urgent Orange 10
3 Urgent Yellow 60
4 Somewhat urgent Green 120
5 Non-urgent Blue 240
White: patients whose condition does not merit emergency/urgent care
Manchester Protocol: A “Common Terminology”
DETERMINANT RISK CLASSIFICATIONAPPROPRIATE
NETWORK SERVICE POINT
IDEAL TREATMENT TIMEFRAME
Adult abdominal pain
Microregional or macroregional hospital *
Treat immediately
In remote areas, transfer within at least 30 minutes
Adult abdominal pain
Microregional hospital **
Treat within no more than 10 minutes
Transfer within no more than 30 minutes
Adult abdominal pain
Microregional
hospital or HPP * **
Treat within 60 minutes.
Same-day transfer (24 hours)
Adult abdominal pain
HPP or UBS Treat within 120 minutes
Adult abdominal pain
HPP, UBS, or residence
Treat within 240 minutes (no more than 24 hours)
MAJOR TRAUMA CARE NETWORK
RESOURCESHOSPITAL
LEVEL 1 LEVEL 2 LEVEL 3
Neurosurgery
Vascular surgery
Angiography
Upon notification: thoracic, cardiac, pediatric, plastic, maxillofacial, and implant surgery
Heliport with exclusive access
Emergency room (Mobile Medical and Basic Support Units)
High-complexity operating room
Computerized tomography
Trauma surgeon
Orthopedist
Emergency room physician
General surgeon
Anesthesiologist
Transfusion unit
Intensive care unit
Step 1. Perform a situation analysis of the emergency/urgent care (EUC)
network
Step 2. Select the model of care for the EUC network
Step 3. Develop the health districts and levels of the EUC network
Step 4. Design the EUC network
Step 5. Build the primary care component of the EUC network
Step 6. Build the secondary and tertiary care levels of EUC network
Step 7. Design network support systems
Step 8. Design network logistical systems
Step 9. Establish oversight systems for the EUC networks
THE ROAD AHEAD THE ROAD AHEAD STEPS FOR STRUCTURING THE EMERGENCY/URGENT CARE SERVICES NETWORK
Mobile Medical Unit (MMU)
Basic Support Unit (BSU)
Advanced Support Unit (ASU)
Command Center
Air Transport Unit (ATU)
Macrohospital
Microhospital
Level III Microhospital
Small-scalehospital
São João do Paraíso
UrucuiaSão Romão
Monte Azul
Manga
Verdelândia
Rio Pardo de Minas
Januária Microhospital
Salinas Microhospital
Bocaiuva Microhospital
Pirapora Microlevel III Trauma Hospital
Brasília de Minas Microlevel III Trauma Hospital
Janaúba Microlevel III Trauma Hospital
MOC Macrolevel I Trauma and Cardiac Hospital, Santa Casa MOC Macrolevel I Trauma
Hospital, Clemente Faria
MOC Macrolevel II Cardiology Hospital, Aroldo Tourinho
Taiobeiras Microlevel III Trauma Hospital
Fundação Dilson GodinhoCoração de Jesus
Francisco Sá
PROPOSED FINANCING OF THE NETWORK
R$ 75,000.00Level I Cardiology Hospital
R$ 50,000.00Level II Cardiology Hospital
-
R$ 320,000.00Level I Trauma and Cardiology Hospital R$ 210,000.00Level II Trauma and Cardiology Hospital R$ 130,000.00Level III Trauma and Cardiology Hospital
R$ 250,000.00Level I Trauma Hospital R$ 180,000.00Level II Trauma Hospital R$ 130,000.00Level III Trauma Hospital
R$ 100,000.00Microregion
R$ 20,000.00Basic Hospitals/Level
COMMAND CENTERCOMMAND CENTER
ResultsResults
Short-Term Evaluation
Process: - Progressive increase in system use:
Calls to Call Center (Jan. 1,742; Aug. 7,882)Pre-hospital ambulance trips (Jan. 883; Aug: 2,904)
Clinical Management: - Shorter decision-making time: critical for the outcome in the U/E- 50% drop in microregional hospital patients in green and blue risk categories: integration of primary care, and Manchester Protocol implemented throughout the network- Clinical reports
Recapping...Recapping...
Emergency care systems should be based on a regional model
Emergency care systems should be under a single authority and their different points of service delivery should be coordinated
Patient flows between points of service delivery and logistics should be based on risk classification
Results of the system must be monitored
System planning and preparations are required to address sudden increases in its use
Oversight is needed to enforce rules (outsourcing) and monitor results
A new financing model is necessary, based on the adjustment of goals (replacing the fee-for-service model)
Emergency care systems should be based on a regional model
Emergency care systems should be under a single authority and their different points of service delivery should be coordinated
Patient flows between points of service delivery and logistics should be based on risk classification
Results of the system must be monitored
System planning and preparations are required to address sudden increases in its use
Oversight is needed to enforce rules (outsourcing) and monitor results
A new financing model is necessary, based on the adjustment of goals (replacing the fee-for-service model)
Recapping...Recapping...
Thank you! Thank you!
Antônio Jorge de Souza MarquesAntônio Jorge de Souza Marques
Thank you! Thank you!
Antônio Jorge de Souza MarquesAntônio Jorge de Souza Marques