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