ABSTRACT
OBJECTIVE: To analyze the process of implementation of emergency care units in Brazil. METHODS: We have carried out a documentary analysis, with interviews with twenty-four state urgency coordinators and a panel of experts. We have analyzed issues related to policy background and trajectory, players involved in the implementation, expansion process, advances, limits, and implementation difficulties, and state coordination capacity. We have used the theoretical framework of the analysis of the strategic conduct of the Giddens theory of structuration. RESULTS: Emergency care units have been implemented after 2007, initially in the Southeast region, and 446 emergency care units were present in all Brazilian regions in 2016. Currently, 620 emergency care units are under construction, which indicates expectation of expansion. Federal funding was a strong driver for the implementation. The states have planned their emergency care units, but the existence of direct negotiation between municipalities and the Union has contributed with the significant number of emergency care units that have been built but that do not work. In relation to the urgency network, there is tension with the hospital because of the lack of beds in the country, which generates hospitalizations in the emergency care unit. The management of emergency care units is predominantly municipal, and most of the emergency care units are located outside the capitals and classified as Size III. The main challenges identified were: under-funding and difficulty in recruiting physicians. CONCLUSIONS: The emergency care unit has the merit of having technological resources and being architecturally differentiated, but it will only succeed within an urgency network. Federal induction has generated contradictory responses, since not all states consider the emergency care unit a priority. The strengthening of the state management has been identified as a challenge for the implementation of the urgency network.
Subject(s)
Emergency Medical Services/organization & administration , Health Plan Implementation/organization & administration , Health Policy , Ambulances/organization & administration , Brazil , Emergency Service, Hospital/organization & administration , Health Services Accessibility/organization & administration , Humans , Patient Care Management/organization & administration , Qualitative ResearchABSTRACT
The Mobile Emergency Medical Service (SAMU) was the first component of the National Policy for Emergency Care implemented in Brazil in the early 2000. The article analyzed the implementation of mobile pre-hospital emergency care in Brazil. The methods included document analysis, interviews with state emergency care coordinators, and an expert panel. The theoretical reference was the strategic conduct analysis from Giddens' Structuration Theory. The results showed uneven implementation of the SAMU between states and regions of Brazil, identifying six patterns of implementation, considering the states' capacity to expand the population coverage and regionalize the service. Structural difficulties included physician retention, poorly equipped dispatch centers, and shortage of ambulances. The North and Northeast were the country's most heavily affected regions. SAMU is formatted as a structuring strategy in the emergency care network, but its performance suffered the impact of limited participation by primary care in the emergency network and especially the lack of hospital beds.
Subject(s)
Ambulances/organization & administration , Emergency Medical Services/organization & administration , National Health Programs/organization & administration , Program Evaluation , Ambulances/standards , Brazil , Emergency Medical Services/standards , Geographic Mapping , Health Services Research , Qualitative Research , Surveys and QuestionnairesABSTRACT
ABSTRACT OBJECTIVE To analyze the process of implementation of emergency care units in Brazil. METHODS We have carried out a documentary analysis, with interviews with twenty-four state urgency coordinators and a panel of experts. We have analyzed issues related to policy background and trajectory, players involved in the implementation, expansion process, advances, limits, and implementation difficulties, and state coordination capacity. We have used the theoretical framework of the analysis of the strategic conduct of the Giddens theory of structuration. RESULTS Emergency care units have been implemented after 2007, initially in the Southeast region, and 446 emergency care units were present in all Brazilian regions in 2016. Currently, 620 emergency care units are under construction, which indicates expectation of expansion. Federal funding was a strong driver for the implementation. The states have planned their emergency care units, but the existence of direct negotiation between municipalities and the Union has contributed with the significant number of emergency care units that have been built but that do not work. In relation to the urgency network, there is tension with the hospital because of the lack of beds in the country, which generates hospitalizations in the emergency care unit. The management of emergency care units is predominantly municipal, and most of the emergency care units are located outside the capitals and classified as Size III. The main challenges identified were: under-funding and difficulty in recruiting physicians. CONCLUSIONS The emergency care unit has the merit of having technological resources and being architecturally differentiated, but it will only succeed within an urgency network. Federal induction has generated contradictory responses, since not all states consider the emergency care unit a priority. The strengthening of the state management has been identified as a challenge for the implementation of the urgency network.
RESUMO OBJETIVO Analisar o processo de implantação das unidades de pronto atendimento no Brasil. MÉTODOS Realizou-se análise documental, entrevistas com 24 coordenadores estaduais de urgência e um painel de especialistas. Analisaram-se questões relativas a: antecedentes e trajetória da política; atores envolvidos na implantação; processo de expansão; avanços, limites e dificuldades de implantação; e capacidade de coordenação estadual. Utilizou-se o referencial teórico da análise da conduta estratégica da teoria da estruturação de Giddens. RESULTADOS As unidades de pronto atendimento foram implantadas a partir de 2007, inicialmente na região Sudeste, e em 2016 existiam 446 unidades de pronto atendimento considerando todas as regiões. Atualmente, há 620 unidades de pronto atendimento em construção, indicando expectativa de expansão. O financiamento federal foi um forte indutor da implantação. Os estados planejaram suas unidades de pronto atendimento, mas a existência de negociação direta entre os municípios e a União contribuiu com o significativo número de unidades de pronto atendimento construídas que não funcionam. Em relação à rede de urgência, há tensão com o hospital pela insuficiência de leitos no país, gerando internação na unidade de pronto atendimento. A gestão das unidades de pronto atendimento é predominantemente municipal, com a maioria das unidades de pronto atendimento localizadas fora das capitais e classificadas como Porte III. Os principais desafios identificados foram: o sub-financiamento e a dificuldade de contratar médicos. CONCLUSÕES A unidade de pronto atendimento tem o mérito de ter recursos tecnológicos e ser arquitetonicamente diferenciada, mas só será bem-sucedida dentro de uma rede de urgência. A indução federal gerou respostas contraditórias, pois nem todos os estados consideram a unidade de pronto atendimento como prioritária. O fortalecimento da gestão estadual foi identificado como desafio para a implantação da rede de urgências.
Subject(s)
Humans , Emergency Medical Services/organization & administration , Health Plan Implementation/organization & administration , Health Policy , Patient Care Management/organization & administration , Brazil , Ambulances/organization & administration , Qualitative Research , Emergency Service, Hospital/organization & administration , Health Services Accessibility/organization & administrationABSTRACT
O Serviço de Atendimento Móvel de Urgência (SAMU) foi o primeiro componente da Política Nacional de Atenção às Urgências implantado no país no começo dos anos 2000. O artigo analisou o processo de implantação da urgência pré-hospitalar móvel no Brasil. Os métodos incluíram análise documental, entrevistas com coordenadores estaduais de urgência e um painel de especialistas. Utilizou-se o referencial teórico da análise da conduta estratégica da Teoria da Estruturação de Giddens. Os resultados evidenciaram uma implantação do SAMU desigual entre estados e regiões, identificando seis padrões de implantação considerando-se a capacidade dos estados de expandir a cobertura populacional e de regionalizar. As dificuldades estruturais incluíram a fixação de médicos, centrais de regulação mal equipadas e escassez de ambulâncias. Norte e Nordeste foram as regiões mais atingidas. O SAMU está configurado como estratégia estruturante da rede de urgências, mas seu desempenho sofreu o impacto da pouca participação da atenção primária na rede de urgências e principalmente da falta de leitos hospitalares.
The Mobile Emergency Medical Service (SAMU) was the first component of the National Policy for Emergency Care implemented in Brazil in the early 2000. The article analyzed the implementation of mobile pre-hospital emergency care in Brazil. The methods included document analysis, interviews with state emergency care coordinators, and an expert panel. The theoretical reference was the strategic conduct analysis from Giddens' Structuration Theory. The results showed uneven implementation of the SAMU between states and regions of Brazil, identifying six patterns of implementation, considering the states' capacity to expand the population coverage and regionalize the service. Structural difficulties included physician retention, poorly equipped dispatch centers, and shortage of ambulances. The North and Northeast were the country's most heavily affected regions. SAMU is formatted as a structuring strategy in the emergency care network, but its performance suffered the impact of limited participation by primary care in the emergency network and especially the lack of hospital beds.
El Servicio de Atención Móvil de Urgencia (SAMU) fue el primer componente de la Política Nacional de Atención a las Urgencias, implantado en Brasil a inicio del año 2000. El artículo analizó el proceso de implantación de la urgencia pre-hospitalaria móvil en Brasil. Los métodos incluyeron un análisis documental, entrevistas con coordinadores estatales de urgencia y un panel de especialistas. Se utilizó el marco referencial teórico del análisis de la conducta estratégica de la Teoría de la Estructuración de Giddens. Los resultados evidenciaron una implantación del SAMU desigual entre estados y regiones, identificando seis patrones de implantación, considerándose la capacidad de los estados de expandir la cobertura poblacional y de regionalizar. Las dificultades estructurales incluyeron la fijación de médicos, centrales de mal equipadas y escasez de ambulancias. Norte y Nordeste fueron las regiones más afectadas. El SAMU está configurado como estrategia estructurante de la red de urgencias, pero su desempeño sufrió el impacto de la poca participación de la atención primaria en la red de urgencias y, principalmente, de la falta de camas en hospitales.
Subject(s)
Program Evaluation , Ambulances/organization & administration , Emergency Medical Services/organization & administration , National Health Programs/organization & administration , Brazil , Surveys and Questionnaires , Ambulances/standards , Qualitative Research , Emergency Medical Services/standards , Geographic Mapping , Health Services ResearchABSTRACT
Introdução Após mais de uma década de implantação do Serviço de Atendimento Móvel de Urgência (SAMU), torna-se importante lançar um olhar crítico a este serviço a fim de identificar as propostas da Política Nacional de Atenção às Urgências. Objetivo - Descrever e analisar criticamente o processo de trabalho da Central de Regulação do SAMU São Paulo (SAMU SP). Métodos Foi realizado um estudo de caso descritivo exploratório, com estratégia de métodos mistos, integrando as abordagens quantitativa (dados secundários referentes ao mês de outubro de 2012) e qualitativa (observação direta e entrevistas com três médicos reguladores). O banco de dados secundários permitiu descrever a demanda do SAMU SP e verificar a existência de padrões de associação entre as variáveis. Foi realizado o cálculo das frequências absolutas e relativas de todas as variáveis categóricas e cálculo dos tempos envolvidos no atendimento préhospitalar. As entrevistas foram transcritas e analisadas por meio da análise de conteúdo de Bardin com o objetivo identificar fatores subjetivos que não foram possíveis de serem mensurados na análise quantitativa. Foi realizada uma segunda análise estatística do banco de dados, com foco no processo de priorização das ocorrências, sendo investigadas as variáveis despacho e tempo de regulação, segundo determinante de prioridade e queixas principais. Foi utilizado o teste chi-quadrado para significância estatística. Resultados - A demanda é majoritariamente clínica (59,2 por cento ), masculina (52,2 por cento ), entre 20 e 59 anos (54,5 por cento ) e classificadas com Determinantes de alta prioridade (Echo e Delta) (52,5 por cento ). As transferências inter-hospitalares correspondem a 0,6 por cento da demanda. A frequência de despacho de ambulância é de 63,4 por cento e decresce conforme a prioridade diminui, chegando a 21,2 por cento no Determinante de menor prioridade (Ômega). O tempo resposta é inversamente proporcional ao Determinante de prioridade, e uma parte significativa de ocorrências de baixa prioridade (35,9 por cento ) são incluídas no sistema de saúde. Foram identificadas três dimensões que influenciam o processo de priorização das ocorrências: condições clínicas reportadas (parada cardiorrespiratória, problemas respiratórios, inconsciência) condições de vulnerabilidade e risco específicos (idosos e crianças abaixo de 3 anos, quedas, medo por parte do médico regulador de subestimar, presença de violência, interação com outros serviços) e condições intrínsecas ao processo de trabalho da central de operações SAMU SP (alta demanda e poucos recursos, trabalho colaborativo com outros profissionais). Conclusões A descrição e análise crítica da demanda e do processo de trabalho do SAMU SP traz elementos para a discussão sobre seu papel dentro do sistema de saúde do município. É possível afirmar que o SAMU SP tem cumprido a missão de salvar vidas, provendo assistência qualificada para pacientes classificados de altíssima prioridade que necessitam de atendimento fora do ambiente hospitalar. Ordenar a demanda de urgência e se configurar como um observatório de saúde passam pela necessidade do reconhecimento técnico e político de que se trata de um serviço integrado a rede de atenção à saúde e não apenas a rede temática da urgência
Introduction After more than a decade of Brazilian Mobile Emergency Services (SAMU) implementation, it becomes importante to launch a critical look at this service in order to identify the proposals of the National Policy for Emergency Care. Objective To critically describe and analyze the work process of SAMU Regulation Center of the city of São Paulo (SAMU SP). Methods A descriptive exploratory case study with mixed methods strategy, integrating the quantitative (secondary data for October 2012) and qualitative (direct observation and interviews with three regulatory physicians) approaches. The secondary database was used to describe SAMU SP demand and to verify the existence of patterns of association between the variables. Absolute and relative frequencies of all categorical variables and the times involved in prehospital care were calculated. The interviews were transcribed and analyzed through Bardin content analysis with the objective of identifying subjective factors that were not possible to be measured in the quantitative analysis. A second statistical analysis of the database was carried out, focusing on the prioritization of emergency incidentes. The frequency of dispatch and regulation time were investigated, according to the Priority Determinant and main complaint. The chi-square test was used for statistical significance. Results - The demand is composed mainly by clinical chief complaints (59.2 per cent ), male patients (52.2 per cent ), between 20 and 59 years old (54.5 per cent ) and classified with high priority determinants (Echo and Delta) (52.5 per cent ). Interhospital transfers correspond to 0.6 per cent of the demand. Ambulance dispatch frequency is 63.4 per cent and decreases as the priority decreases, reaching 21.2 per cent in the lowest Priority Determinant (Omega). The response time is inversely proportional to the Priority Determinant, and a significant portion of low priority occurrences (35.9 per cent ) are included in the health system. Three dimensions have been identified that influence the prioritization of emergency incidents: reported clinical conditions (cardiorespiratory arrest, respiratory problems, unconsciousness), vulnerable conditions and specific risk of the emergency incident (elderly and children under 3 years, falls, medical doctor fear of underestimation, presence of violence, interaction with other services) and work process intrinsic conditions of SAMU SP operations center (high demand and few resources, collaborative work with other professionals). Conclusions The description and critical analysis of the demand and work process of the SAMU SP brings elements to the discussion about its role within the health system of the city of São Paulo. It is possible to affirm that SAMU SP has fulfilled the mission of saving lives, providing qualified assistance to patients classified as high priority who need care outside the hospital environment. In order to SAMU SP organize the demand for urgent care and to be a health observatory, there is the need of technical and political re-recognition that it is a service integrated to the health care network and not just a thematic network of urgency
Subject(s)
Ambulances/organization & administration , Emergency Medical Services/organization & administration , Transportation of Patients/organization & administration , BrazilABSTRACT
The demand for highly efficient and effective services and consumer goods is an essential prerequisite for modern organizations. In healthcare, efficiency and effectiveness mean reducing disabilities and maintaining human life. One challenge is guaranteeing rapid Emergency Medical Service (EMS) response. This study analyzes the EMS of Belo Horizonte, Brazil, using two modeling techniques: optimization and simulation. The optimization model locates ambulance bases and allocates ambulances to those bases. A simulation of this proposed configuration is run to analyze the dynamic behavior of the system. The main assumption is that optimizing the ambulance base locations can improve the system response time. Feasible solutions were found and the current system may be improved while considering economic and operational changes.
Subject(s)
Efficiency, Organizational , Emergency Medical Services/organization & administration , Models, Theoretical , Ambulances/organization & administration , Brazil , Computer Simulation , Humans , Time FactorsABSTRACT
Este estudio investiga las causas de demora en los tiempos de respuesta a códigos amarillos en un servicio privado de emergencias médicas de la ciudad de Córdoba, que cuenta con afiliados directos y por convenios, estos últimos representan un 70% del total. Los nivel de prestaciones son diferenciados por códigos según riesgo de vida y/o por tiempo de respuesta en: Verde (consultas o demora hasta 3 horas), Amarillos (urgencias o demora hasta 20 minutos), Rojos (emergencias o demora hasta 12 minutos) Azul (traslados, sin demora establecida)...
Summary: This study investuigates the causes of delay in response times to yellow code in a private emergency medical service of the city of Córdoba, which has direct and affiliate agreements, the latter account for 70% of the total. Performance levels are differentiated by codes as life-threatening and/ or response time: Green (queries or delay up to 3 hours), Yellow (emergency or delay up to 20 minutes), Reds (emergencies or delay up to 12 minutes) blue (trasfers, established without delay)...
Subject(s)
Male , Female , Humans , Ambulances , Ambulatory Care , Emergencies , Emergency Medicine/organization & administration , Ambulances/organization & administration , Time Management , ArgentinaABSTRACT
El documento tiene algunos problemas de nitidez, que dificultan un tanto su lectura. Su objetivo es la regulación del procedimiento de autorización y funcionamiento en dichas unidades móviles (tipo ambulancia). Se establecen así mismo, los requisitos y características que deberán cumplirse en estas unidades, tanto terrestres, marítimas como aéreas. Esto incluye al personal que las maneja. Incluye un listado de términos técnicos referidos al tema principal. Presenta también las características técnicas así como el perfil del personal que las maneja además de la infraestructura y el equipo de deben contener para proveer del cuidado médico adecuado.
Subject(s)
Humans , Male , Female , Ambulances/legislation & jurisprudence , Allied Health Personnel/legislation & jurisprudence , Ambulances/organization & administration , Allied Health Personnel/organization & administration , Prehospital Care/standards , GuatemalaABSTRACT
INTRODUCTION: In most places all over the worldincluding our countryservices in emergency rooms are oversaturated. This situation frequently forces the continuously arriving ambulances to be redirected to other medical units, delaying the admission of patients moved and thus adversely affecting their physical condition. OBJECTIVE: To introduce an improvement to the Índicede Saturación Modificado computational system, which monitors the degree of saturation of a network of emergency medical services, to include a network of ambulances, enabling in the system: (i) the effective allocation of ambulances to the site of the accident, or severe clinical event, and (ii) the remote booking of beds in the nearest and least saturated emergency room available. MATERIAL AND METHODS: The evaluation and connectivity of the computational improvement to the Índicede Saturación Modificado system was carried out with a computational test verifying these two aspects, using only differences in postal codes, for time measuring. RESULTS: The verification of its sustainability online showed the new Índice de Saturación Modificado y Ambulancias system (ISMA) has a robust structure capable of being adapted to mobile phones, laptops or tablets, and can efficiently administrate: (i) the quantification of excessive demand in the emergency room services of a hospital network, (ii) the allocation of ambulances attending the site of the event or contingency, and (iii) the allocation of ambulances and patients, in the best distance-time conditions, from the site of the accident or clinical event to the nearest and least saturated emergency room service. CONCLUSIONS: This administrative management tool is efficient and simple to use, and it optimally relates independent service networks.
Subject(s)
Ambulances/organization & administration , Emergency Medical Service Communication Systems , Emergency Service, Hospital/organization & administration , Cell Phone , Computers, Handheld , Humans , MexicoABSTRACT
A catastrophic earthquake of the magnitude of 7 on the Richter scale hit Haiti's capital Port-au-Prince on Tuesday January 12, 2010 at a focal depth of 13 km or 8.1 miles. Four days after, a joint Ministry of Health (Jamaica)/Jamaica Medical Doctor Association (JMDA) initiated CARICOM (Caribbean Community) endeavour entered Haiti to establish a system whereby medical help could be offered to the Haitian populace. Two hospital sites were established (one for life-saving surgeries, the other for limb reconstructions), clinic facilities for walk-in wounded and other related cases, and mobile clinic services (called the Train of Hope). Within 48 hours, a total of 43 operations were performed (26 major 17 minor). Within eight days, a total of 1229-1249 patients were seen in all the facilities established. This included a total of 106 operations (64 major 42 minor). There were a total of 21 life-saving amputations.
Subject(s)
Disasters , Earthquakes , Emergency Responders , Ambulances/organization & administration , Disaster Planning , Haiti , HumansABSTRACT
O estudo objetivou relatar a experiência na implantação e estruturação do projeto do Serviço Móvel de Urgência (SAMU-192), em Salvador, cujas bases legais foram portarias do Ministério da Saúde e a Norma Operacional de Assistência à Saúde 02/2002. O serviço tem como finalidade prestar assistência gratuita ao indivíduo, em um primeiro nível de atenção, com agravos de natureza clínica, cirúrgica, traumática e psiquiátrica que acarretam sofrimento, seqüelas ou morte e ocorrem fora do ambiente hospitalar. O objetivo específico foi garantir o atendimento às situações de urgência e emergência por meio do SAMU-192, regulado, hierarquizado e integrado ao Sistema Único de Saúde, assegurando recursos públicos inclusive integrados à rede complementar de assistência. Despesas para sua instalação foram pactuadas no município e em comissões intergestoras federal e estadual. Os desafios do serviço incluem educação comunitária, capacitação profissional, avaliação de recursos humanos e materiais, na dinâmica e qualidade da atenção.
The goal of this study was to describe the implementation of the emergency ambulance service of Salvador, Bahia (SAMU-192). The Ministry of Health provided the legal basis and regulations for its implementation. The main purpose of this service is the provision of free primary level healthcare to individuals, with clinical, surgical, traumatic and psychiatric aggravations that cause suffering, sequels or death and occur outside the hospital environment. The specific goals of SAMU-192 was to grant free healthcare to urgency and emergency situations, under the hierarchy and regulations of the Single Health System (SUS) of the Brazilian government, assuring that public resources will be available and integrated to the complementary healthcare network. Investments for the installation of the service were agreed on in the city and with federal and state management commissions. To turn SAMU-192 into reality, several challenges need to be accomplished, including community education, professional qualification and evaluation of human and material resources so as to provide basic emergency care with the appropriate quality.
El estudio tuvo por objetivo narrar la experiencia sobre la implantación y estructuración del proyecto de Servicio de Urgencia Móvil (SAMU-192) en Salvador, basado legalmente por decretos del Ministerio de Salud y la Norma Operacional de Asistencia a la Salud 02/2002. La finalidad del servicio es brindar asistencia gratuita fuera del hospital al individuo en un primer nivel de atención, en casos de tipo clínico, quirúrgico, traumático y psiquiátrico que provocan sufrimiento, secuelas o muerte. El objetivo específico fue garantizar la atención en casos de urgencia y emergencia a través del SAMU-192, reglamentado, jerarquizado e integrado al Sistema Único de Salud, asegurando recursos públicos, inclusive integrados a la red complementaria de asistencia. Gastos por instalación fueron establecidos entre la municipalidad y comisiones inter-gestoras federales y estatales. Como retos en la dinámica y calidad de la atención: educación comunitaria, capacitación profesional, evaluación de recursos humanos y materiales.
Subject(s)
Humans , Ambulances/organization & administration , Ambulances/legislation & jurisprudence , Brazil , Delivery of Health Care, Integrated/organization & administration , Emergency Medical Services/legislation & jurisprudence , Emergency Medical Services/organization & administration , Health Services Needs and DemandABSTRACT
The goal of this study was to describe the implementation of the emergency ambulance service of Salvador, Bahia (SAMU-192). The Ministry of Health provided the legal basis and regulations for its implementation. The main purpose of this service is the provision of free primary level healthcare to individuals, with clinical, surgical, traumatic and psychiatric aggravations that cause suffering, sequels or death and occur outside the hospital environment. The specific goals of SAMU-192 was to grant free healthcare to urgency and emergency situations, under the hierarchy and regulations of the Single Health System (SUS) of the Brazilian government, assuring that public resources will be available and integrated to the complementary healthcare network. Investments for the installation of the service were agreed on in the city and with federal and state management commissions. To turn SAMU-192 into reality, several challenges need to be accomplished, including community education, professional qualification and evaluation of human and material resources so as to provide basic emergency care with the appropriate quality.
Subject(s)
Ambulances/organization & administration , Ambulances/legislation & jurisprudence , Brazil , Delivery of Health Care, Integrated/organization & administration , Emergency Medical Services/legislation & jurisprudence , Emergency Medical Services/organization & administration , Health Services Needs and Demand , HumansABSTRACT
BACKGROUND: The public health system of Brazil is structured by a network of increasing complexity, but the low resolution of emergency care at pre-hospital units and the lack of organization of patient flow overloaded the hospitals, mainly the ones of higher complexity. The knowledge of this phenomenon induced Ribeirão Preto to implement the Medical Regulation Office and the Mobile Emergency Attendance System. The objective of this study was to analyze the impact of these services on the gravity profile of non-traumatic afflictions in a University Hospital. METHODS: The study conducted a retrospective analysis of the medical records of 906 patients older than 13 years of age who entered the Emergency Care Unit of the Hospital of the University of São Paulo School of Medicine at Ribeirão Preto. All presented acute non-traumatic afflictions and were admitted to the Internal Medicine, Surgery or Neurology Departments during two study periods: May 1996 (prior to) and May 2001 (after the implementation of the Medical Regulation Office and Mobile Emergency Attendance System). Demographics and mortality risk levels calculated by Acute Physiology and Chronic Health Evaluation II (APACHE II) were determined. RESULTS: From 1996 to 2001, the mean age increased from 49 +/- 0.9 to 52 +/- 0.9 (P = 0.021), as did the percentage of co-morbidities, from 66.6 to 77.0 (P = 0.0001), the number of in-hospital complications from 260 to 284 (P = 0.0001), the mean calculated APACHE II mortality risk increased from 12.0 +/- 0.5 to 14.8 +/- 0.6 (P = 0.0008) and mortality rate from 6.1 to 12.2 (P = 0.002). The differences were more significant for patients admitted to the Internal Medicine Department. CONCLUSION: The implementation of the Medical Regulation and Mobile Emergency Attendance System contributed to directing patients with higher gravity scores to the Emergency Care Unit, demonstrating the potential of these services for hierarchical structuring of pre-hospital networks and referrals.
Subject(s)
Emergency Medical Services/organization & administration , Emergency Service, Hospital/statistics & numerical data , Hospitals, University , Regional Medical Programs/organization & administration , APACHE , Adolescent , Adult , Aged , Aged, 80 and over , Ambulances/legislation & jurisprudence , Ambulances/organization & administration , Brazil , Female , Health Plan Implementation , Hospitals, University/statistics & numerical data , Humans , Logistic Models , Male , Middle Aged , Patient Transfer , ROC Curve , Referral and Consultation , Retrospective Studies , Utilization ReviewABSTRACT
OBJECTIVE: Prehospital care is a critical component of efforts to lower trauma mortality. In less-developed countries, scarce resources dictate that any improvements in prehospital care must be low in cost. In one Latin American city, recent efforts to improve prehospital care have included an increase in the number of sites of ambulance dispatch from two to four and introduction of the Prehospital Trauma Life Support (PHTLS) course. METHODS: The effect of increased dispatch sites was evaluated by comparing response times before and after completion of the change. The effect of PHTLS was evaluated by comparing prehospital treatment for the 3 months before initiation of the course (n = 361 trauma patients) and the 6 months after (n = 505). RESULTS: Response time decreased from a mean of 15.5 +/- 5.1 minutes, when there were two sites of dispatch, to 9.5 +/- 2.7 minutes, when there were four sites. Prehospital trauma care improved after initiation of the PHTLS course. For all trauma patients, use of cervical immobilization increased from 39 to 67%. For patients in respiratory distress, there were increases in the use of oropharyngeal airways (16-39%), in the use of suction (10-38%), and in the administration of oxygen (64-87%). For hypotensive patients, there was an increase in use of large-bore intravenous lines from 26 to 58%. The improved prehospital treatment did not increase the mean scene time (5.7 +/- 4.4 minutes before vs. 5.9 +/- 6.8 minutes after). The percent of patients transported who died in route decreased from 8.2% before the course to 4.7% after. These improvements required a minimal increase (16%) in the ambulance service budget. CONCLUSION: Increase in sites of dispatch and increased training in the form of the PHTLS course improved the process of pre-hospital care in this Latin American city and resulted in a decrease in prehospital deaths. These improvements were low cost and should be considered for use in other less developed countries.