QUALITY IMPROVEMENT OF HEALTH CARE SERVICES IN CROATIAN EMERGENCY MEDICINE

Danas je zdravstvena zaštita u djelatnosti hitne medicine u Republici Hrvatskoj organizirana kao dio postojećeg sustava zdravstvene zaštite, u izvanbolničkoj i bolničkoj hitnoj medicinskoj službi. Sadašnja organizacija ne ispunjava osnovne kriterije optimalnog funkcioniranja: jednakost, dostupnost, učinkovitost i opremljenost, iz čega je proizašla potreba za reorganizacijom sustava hitne medicinske pomoći. Reorganizacija obuhvaća osnivanje Hrvatskog zavoda za hitnu medicinu, osnivanje 21 županijskog zavoda za hitnu medicinu, uspostavu prijamno-dojavnih jedinica, objedinjavanje hitnog prijma u bolnicama, integraciju telemedicine u djelatnost hitne medicine, uvođenje specijalizacije hitne medicine za doktore medicine i dodatnog specijalističkog stručnog usavršavanja iz hitne medicinske pomoći za medicinske sestre-medicinske tehničare, odvajanje sanitetskog prijevoza, standardizaciju medicinske opreme i vozila i izradu smjernica/protokola/algoritama postupaka zbrinjavanja. Tijekom 5 godina od početka reorganizacije cilj je postići: vrijeme dolaska tima izvanbolničke službe k pacijentu do deset minuta unutar urbanog područja, te dvadeset minuta u ruralnim područjima u 80% intervencija; interval dojava - dolazak pacijenta u bolnicu unutar „zlatnog sata“ u 80% slučajeva; 200 doktora medicine sa završenom specijalizacijom hitne medicine i 220 medicinskih sestaramedicinskih tehničara za završenim dodatnim specijalističkim stručnim usavršavanjem iz hitne medicinske pomoćiEmergency medical services (EMS) in the Republic of Croatia are currently organized as part of the existing health care system and delivered in the form of pre-hospital and hospital EMS. The pre-hospital EMS are delivered by standalone EMS Centers, EMS units set up in community health centers, and by general practitioners working in shifts and on call in remote and scarcely populated areas. In hospitals, each ward usually has its own emergency reception area, and only in a couple of cases there is an integrated emergency admission unit for the entire hospital. The current EMS structure does not meet the basic requirements that would make an EMS system optimal, i.e. equal quality, equal access, effectiveness and appropriate equipment. The EMS Restructuring Project is part of the Croatian health care system reform and is addressed by the National Health Development Strategy 2006-2011. As part of restructuring efforts, the Croatian National Institute of Emergency Medicine, 21 County Institutes of Emergency Medicine and county-level call centers are going to be set up. In addition, the project will introduce the following: integrated emergency admission areas at hospitals; telemedicine as part of emergency medicine; emergency medicine specialty for physicians and additional specialized training for nurses/technicians; separation of emergency and non-emergency transport; standards for vehicles and equipment and guidelines/protocols/algorithms for care. The Croatian National Institute of Emergency Medicine is an umbrella EMS organization. It shapes the EMS in Croatia and proposes, plans, monitors and analyzes EMS actions in Croatia. In addition, it submits a proposal of the Emergency Medicine Network to the minister, sets standards for EMS transport, and coordinates, guides and supervises the work of County Institutes of Emergency Medicine. County Institutes organize and deliver pre-hospital EMS in their counties. Integrated hospital emergency admission units represent a single point of entry for all emergencies at a particular hospital. Upon triage, depending on the level of emergency, patients are provided with appropriate care and treatment. The introduction of EMS specialty for physicians and additional specialized training for nurses/ technicians is going to increase competencies of all EMS team members. The main objectives of the EMS Restructuring Project to be achieved in the 5-year period are the following: to reduce the response time of pre-hospital EMS teams to 10 minutes in urban areas and 20 minutes in rural areas in 20% of team interventions; to bring patients to hospital within the “golden hour” in 80% of cases; to have 200 physicians specialized in emergency medicine; and to have 220 nurses/technicians that have successfully completed their specialized training in emergency medicine. The objectives are going to be monitored through indicators as part of the World Bank Project for which data have already been collected throughout Croatia: number of interventions; number of emergency interventions; time between call receipt and arrival to scene; time between call receipt and arrival to hospital emergency reception area; percentage of arrivals to hospital by EMS vehicles within 12 hours of symptom onset; polytrauma and cardiac arrest survival rate before admission to hospital; time spent in hospital emergency reception areas and integrated hospital emergency admission units; polytrauma and cardiac arrest survival rate within 24 hours of hospital admission; number of integrated hospital emergency admission units per county; and number of pre-hospital EMS teams per capita

Application of National Guidelines for Pre-hospital and Hospital Emergency Medical Services for Patients Who Require Palliative Care

U zbrinjavanju palijativnog pacijenta sudjeluje cijeli niz stručnjaka, uključujući i tim hitne medicinske službe. Cilj i svrha palijativne skrbi je održati i unaprijediti kvalitetu života palijativnih pacijenata kroz kontrolu simptoma i pružanje pacijentima psihološke, duhovne i socijalne podrške. Nacionalne smjernice za rad izvanbolničke i bolničke hitne medicinske službe s pacijentima kojima je potrebna palijativna skrb sadrže opće informacije o palijativnoj skrbi, opise hitnih stanja uz specifično kliničko prosuđivanje pri zbrinjavanju pacijenta, važnost i način komunikacije s pacijentom i obitelji, koji obuhvaća savjetovanje obitelji umirućeg pacijenta, odlučivanje o primjerenosti medicinskih postupaka i način priopćavanja loše vijesti.The palliative patient is cared for by many professionals, including the emergency medical team. The goal and purpose of palliative care are to maintain and improve the quality of life of palliative patients through symptom control, as well as psychological, spiritual, and social support. The national guidelines for pre-hospital and hospital emergency medical services for patients requiring palliative care provide general information about palliative care, descriptions of emergencies with specific clinical assessments in patient care, the importance and way of communicating with a patient and their family, including counseling a terminal patient’s family, deciding on the appropriateness of medical procedures, and communicating bad news

The response of the health system to major traffic accidents

U Republici Hrvatskoj su u 2021. godini u prometnim nesrećama život izgubile 292 osobe, najviše u ljetnim mjesecima. Hrvatska je od 1994. do danas izradila više nacionalnih strategija sigurnosti cestovnog prometa, a posljednju je za razdoblje 2021. – 2030. godine donijela Vlada Republike Hrvatske. Primjetan je trend smanjenja poginulih osoba u prometu u odnosu na početak provedbe te je broj poginulih osoba u prometu gotovo tri puta manji u odnosu na 1994. godinu. U prometnoj nesreći 25. srpnja 2021. na autocesti A3 kod Slavonskog Broda stradalo je 69 putnika autobusa koji je sletio s ceste. Deset osoba je smrtno stradalo, a 42 ih je zaprimljeno na bolničko liječenje. Druga velika prometna nesreća autobusa dogodila se 6. kolovoza 2022. na autocesti A4 u kojoj je smrtno stradalo 12 osoba, a 32 osobe su hospitalizirane. Brz, koordiniran, uvježban i kvalitetan odgovor svih hitnih službi uključenih u zbrinjavanje velikih nesreća zadaća je svih koji u njemu sudjeluju. Djelatnici hitne medicinske službe, pripadnici policije, vatrogasaca i civilne zaštite od 2009. godine uvježbavaju svoje koordinirano djelovanje na tečaju Medicinskog odgovora na velike nesreće MRMI (engl. Medical Response to Major Incidents) u suradnji Kriznog stožera Ministarstva zdravstva, Hrvatskog zavoda za hitnu medicinu, Hrvatskog društva za medicinu katastrofe i Opće bolnice “Dr. Josip Benčević” Slavonski Brod. Ovaj poslijediplomski tečaj provodi se u 12 europskih zemalja, a polaznici kroz stvaran scenarij zbrinjavanja velike nesreće s realnim utroškom vremena, osoblja i resursa uvježbavaju svoja teorijska i praktična znanja i vještine na svim lokacijama uključenim u zbrinjavanje jedne takve nesreće, od mjesta događaja do konačnog zbrinjavanja u operacijskim salama i jedinicama intenzivnog liječenja.In the Republic of Croatia in 2021, 292 people lost their lives in traffic accidents, mostly in the summer months. From 1994 to the present day, Croatia has drawn up several national road safety strategies, and the latest one for the period 2021–2030 was adopted by the Croatian Government. There is a noticeable trend of decreasing traffic fatalities compared to the beginning of the inspection, and the number of traffic fatalities is almost three times lower than in 1994. In a traffic accident on July 25, 2021, on the A3 highway near Slavonski Brod, 69 passengers were traveling in a bus that went off the road. Ten people died, and 42 were admitted to hospital. The second major bus accident occurred on August 6, 2022, on the A4 highway, in which 12 people died and 32 people were hospitalized. A quick, coordinated, trained and high-quality response of all emergency services involved in dealing with major accidents is the task of all those who participate in it. Since 2009, employees of the emergency medical service, members of the police, firefighters and civil protection have been practicing their coordinated actions at the Medical Response to Major Incidents (MRMI) course in cooperation with the Crisis Headquarters of the Ministry of Health, the Croatian Institute of Emergency Medicine, the Croatian Society for disaster medicine and General Hospital “Dr. Josip Benčević” Slavonski Brod. The course is carried out in 12 European countries, it’s participants practice their theoretical and practical knowledge and skills through a real scenario of handling a major accident with realistic time consumption, staff and resources in all locations involved in handling such accident, from the scene to operating rooms and intensive care units

PREVENTIVE WORK IN FAMILY MEDICINE – PROACTIVE APPROACH

Uloga liječnika opće/obiteljske medicine u prevenciji bolesti i promociji zdravlja potvrđena je rezultatima istraživanja te u zdravstvenoj politici. S obzirom na položaj liječnika opće/obiteljske medicine u zdravstvenom sustavu i njegov bliski, trajni kontakt s populacijom koja ga je izabrala te s lokalnom zajednicom u kojoj djeluje, razumljivo je da je liječniku opće/obiteljske medicine preventivni rad uključen kao neodvojivi dio redovitog, uobičajenog rada u praksi. Skrb za bolesnika u općoj medicini je kompleksna i proteže se od intervencija u determinantama zdravlja do palijativne skrbi. Preventivne aktivnosti su više ili manje prisutne na svakom odsječku tog procesa. Postoji značajan raskorak između znanja liječnika opće/obiteljske medicine i postojeće prakse u korištenju na znanstvenim dokazima utemeljenih preporuka za aktivnosti u promociji zdravlja i prevenciji bolesti. Opisali smo ulogu liječnika opće obiteljske medicine u preventivnom radu i prikazali podatke o preventivnima aktivnostima u službi obiteljske medicine u Hrvatskoj. Za pravu ocjenu preventivnog rada obiteljskih liječnika potrebno je raspolagati objektivnim na znanstvenim dokazima utemeljenim podacima koji će pokazati što obiteljski liječnici rade u praksi. Zbog toga je nužno da liječnici sistematski bilježe i evaluiraju relevantne preventivne aktivnosti i aktivnosti koje provode u promociji zdravlja, a da se njihovo izvršenje programa redovito prati, evaluira te profesionalno i financijski vrednuje. Prema tim je principima Stručna radna skupina za koordinaciju, praćenje i usmjeravanje reforme u obiteljskoj medicini Ministarstva zdravstva i socijalne skrbi Republike Hrvatske izradila program preventivnih aktivnosti u obteljskoj medicini koji je prikazan u ovom raduThe role of general practitioner/family physician (GP/FP) in disease prevention and health promotion is strongly supported by research and health policies. The position of GPs/FPs in the health care system and their close, sustained contact with their patients and local community makes preventive care an integral part of GP/FP routine work. The spectrum of caring for patients in general practice/family medicine is actually very large, going from intervention on health care determinants to palliative care. The prevention-related activities are more or less present at each step of this “healthcare continuum”. The significant gaps between GP/FP knowledge and practices persist in the use of evidence-based recommendations for health promotion and disease prevention. We describe the role of GP/FP in preventive care and report data on preventive care activities in the Croatian Family Medicine Service. More objective evidence is needed to see what GPs/FPs actually do in practice. For this reason, it is critical that GPs/FPs systematically record the most relevant preventive and health promotion activities that they perform. Furthermore, their performance of the preventive program should be regularly monitored, evaluated and professionally and financially validated. We present the preventive program based on these principles in Family Medicine Service proposed by the Ministry of Health and Social Welfare Working Group on Reform of Primary Health Care