Kuspayev E.N., Nurasheva S.K., DeLellis N.O., Zhuzzhanov O.T., Dubitskii A.A.

«Àstana medical University», Kazakhstan

Emergency and Urgent Medical Services before Admission to a Hospital

Hospital admission in the Republic of Kazakhsta (RK) usually is based either on a referral from primary care physician, self-referral or on the decision of MET. In all the cases hospital admission department is taking the major role in decision-making process on diagnosis, health condition assessment and on necessity of hospitalization for each patient.

An admitting physician should in short time to determine the diagnosis, to appoint additional methods of diagnostics for specification of the diagnosis and to appoint treatment. During that short time the physician should estimate symptoms, examine the patient and, most of all, to prescribe a minimum of diagnostic procedures for faster diagnosis specification. The correct diagnosis and effective treatment, which should lead to the faster recovery, are required by both healthcare system and by the patients themselves [1].

The hospital admission departments rendering the specialized services to the emergency patients are required to provide the appropriate quality of medical aid. According to A.Tsoy [2] most important criteria of quality assessment for medical services, in opinion of patients, are the level of medical qualification and high professionalism (39%), comprehensive and fast performance of diagnostics and treatment (33%), sensitive and attentive attitude to the patients (44%), organization in work (14 %) [2].

The appropriate quality of medical services is a compliance of provided medical services to modern requirements for necessary level and volume for the given kind of a pathology, individual patient characteristics and capability of the specific medical organization [3]. According to A.Taizhanov, to assess healthcare system, assessment indicators should include access, quality, timeliness of medical aid, number of inpatient and outpatient visits, date of last complex physical examination, availability of expensive medical services, frequency and reasons of the patients visits for paid medical services [4].

Materials and methods. The research was based on the quality indicators of medical emergency services for the adult population in Astana in 2005-2009 years. The study included comparative analysis of demographic dynamics of the city, number of calls for MET and the number of hospital admissions and outpatient visits.

The time of stay of the patient in a hospital emergency reception was calculated as time from the moment of the patient appearance in a hospital up to the moment of either patient hospitalization, or refusal in hospitalization based on the diagnosis.

The number/rate of the patient’s hospital admission with prior refusal in admission was analyzed. The study analyzed a) the match between the subsequent and the initial diagnosis, reason for refusal in hospitalization at the primary reference of the patients, b) the divergence between the clinical final diagnoses established in specialized hospital department and the initial diagnoses, established in a reception, and c) the factors affecting the divergence of the diagnoses.

The study conducted a survey of patients (n=304) from the “Central Railway Hospital” in Astana to assess patients’ satisfaction by organization of work of medical emergency team (MET) and ED. All respondents were divided into 3 groups: 1 group included the people, whose medical examination didn’t found the reason for hospital admission and therefore they were released home. 2^nd group was presented by patients without an emergency pathology who were directed on examination and treatment in an outpatient clinic. 3^rd group included the patients with an acute pathology, who were directed for the treatment in hospital.

Final results. After relocation of Kazakhstan capital to Astana in 1997, the population of capital city keeps growing.

According to a demographic year-book [5] the population of city Astana in 2009 in comparison with parameters of 2005 has increased on 20,8 %. Thus the rate of a gain of the population constantly raises: if after 2005 the population of city has grown on 3,9 %, for 2006 on 4,4 %, for 2008 on 4,9 %, for 2008 the population of city has increased on 6,1 % (ð < 0,05).

In the analysis of quantity of calls of brigades of the first help for last years the constant increase is marked also. So, with 2005 on 2009 years The quantity of calls has increased on 42,5 %, that on 21,7 % there is more gain of the population of city. It testifies that the reference for the first help is constantly increased and outstrips rates of a gain of a population.

In general structure of calls of brigades of the first help per researched years first a place is occupied by diseases intimately - vessels systems (15,1 % in 2005ã. and 14,3 % in 2009ã.), on the second place of a trauma (13,4 % in 2005ã. and 11,1 % in 2009ã.), on third - pathology stomach - intestinal of a path (10,4 % in 2005ã. and 9,7 % in 2009ã.). Analyzing dynamics of calls during last five years, it is necessary to note, that significant growth of calls are connected to the not emergency indications, with condition, with which it was possible to address to polyclinic on a residence. So, for example, in 2005 the doctors of first aid ascertained, that the patient practically is healthy in 778 cases, in 2009 the quantity of such calls has increased on 62,3 %; the diagnosis gastritis or duodenitis in 2005 was exposed in 2156 cases, in 2009 the increase of similar calls at 65,5 % is marked; In 2005 108 patients the diagnosis myositis was exposed, in 2009 the increase of calls concerning myositis on 91,7 % is marked. In rare cases such patients are delivered and more less often are directed for the treatment to hospital. Thus, in dynamics the main growth of not profile calls is marked. It is necessary also to note increase in 2,5 times of quantity of calls connected to sorts, from 4643 in 2005 up to 11461 in 2009.

In spite of the fact that the increase of quantity of the delivered patients in hospitals from 19,5 % from general (common) number of calls in 2005 up to 23,7 % in 2009 is marked; percent of the hospitalized patients from general number of calls has decreased from 13,7 % in 2005 to 12,6 % in 2009. Therefore, parameter of percent of hospitalization attitude hospitalized patients to quantity from 70,4 % in 2005 to 53,3 % in 2009.

The changes of demographic parameters in Astana have resulted not only in general increase of quantity of the inhabitants, but also decrease of a parameter " average age of the inhabitant " till 31,3 years in 1999. Within next following years the gradual increase of the given parameter till 32,6 years in 2005 and 34,2 years in 2009 is marked. Together with it, the constant increase of quantity f the city dwellers is marked is more senior than 60 years from 8,37 % in 2005 up to 9,77 % in 2009. Thus, it is necessary to expect increasing the reference of the patients with intimate - vessels by diseases, which basically are shown in elderly and senile age.

In subsequent, the analysis of dynamics of quantity cured of the patients in hospitals of city is carried spent. Quantity of the patients delivered by a brigade of first aid and hospitalized in hospitals from 2005 to 2009 years. Has increased on 31,5 %, that is comparable to increase of a population of city (20,8 %). However, total cured of the patients has increased considerably. So, in 2005 the quantity cured of the patients in the first urban hospital of city Astana has made 14809, in 2009 the given parameter has increased on 52,5 %, at the National scientific medical centre on 52,4 %, in research traumatology and orthopedic institute the quantity cured of the patients for this period has raised (increased) on 36,8 %.

For comparison of the received results we investigate dynamics (changes) of quantity cured of cases in hospital of the first help of. Aktobe city (Western region of Kazakhstan), where the population during the researched years remained practically stable. Quantity of cured patients within 2005, 2009 years in dynamics statistically meaning has not changed, at the same time quantity of the traumatologic and neurosurgical patients tends to decrease to( 9,8 % and 16,3 % accordingly).

Thus, the quantity of treated patients in hospitals of Astana is constantly increased, outstripping the rates of increasing of a population. The given fact, most of all, is closely connected with hospitalization and treatment of the patients from other regions of Kazakhstan.

For an estimation of quality of job of a reception it is offered to use parameters time of staying the patient in a reception, divergence of the preliminary and clinical diagnoses, repeated reference (manipulation) of the patients with the subsequent hospitalization, satisfaction of the patients by the rendered help.

At receipt of the patient in a reception will originally be examined by the profile expert, which nominates the plan diagnostic inspection. The survey of the expert, on the average, borrows (occupies) 12,3±3,4 mines. The average time of definition of the general (common) analysis of blood makes 17,1±3,5 mines., ultrasonic research belly of a cavity 12,6±2,9 mines., survey X-ray radigraphy of bodies belly of the cavity or chest of a crate 11,8¸4,3 mines., the electrocardiogram 6,2±2,1 mines., gastrofibroscopy a gullet and stomach 19,4±3,1 mines. Summarizing the quantity of procedures, it shows, that the average time of stay of the patient with a sharp pathology belly of a cavity makes not less than 40 mines. With the purpose of optimization of job and reduction of time of stay of the patient in a reception is developed and the necessary minimal list of inspection is introduced which can be carried spent already before arrival of the expert. So, patient with an emergency pathology belly of a cavity the general analysis of blood, biochemical parameters general and direct bilirubin, general fiber and diastasis of blood) is necessary to determine, to make ultrasound research belly of a cavity. With the help of the introduced algorithms of diagnostics it was possible to reduce time of stay of the patient in a reception to 8,6±2,7 mines (ð < 0,05).

At the analysis of histories of illnesses of the hospitalized patients is revealed, that in 4,5 % of cases the divergence of the preliminary diagnosis established in a reception, and clinical diagnosis established in profile branch hospitals after complete inspection of the patient. Has been established, that underestimation of a condition of the patient and extravagance of minor attributes of disease in most cases takes place. So, instead of the seldom meeting diagnoses a thrombosis mesenteric vessels of vessels or stratifying an aortic aneurysm, the patients were hospitalized with "the working diagnoses " sharp a pancreatitis and coronary illness accordingly. The realization of additional methods of research at receipt of the patient in a reception has allowed in 15 cases on pre-hospital stage to establish the correct diagnosis.

As the following indicator of an estimation of quality of job of a reception the parameter of the repeated reference of the patients behind medical aid, with the subsequent hospitalization is offered. On the data of conducted research in Astana the given parameter has made 4,5 cases on 10000 references of medical need. It has been established, that in 64,5 % of cases at the repeated reference the diagnosis to some extent corresponded to the diagnosis established at the primary manipulation, but the underestimation of a condition of the patient took place. In 35,5 % of cases the diagnosis, established at the repeated reference was not corresponded to the initial diagnosis. Analyzing the reasons of refusal in hospitalization at the primary reference is revealed, that by the basic reason of refusal was the underestimation of symptoms of disease, weak expressiveness of clinical displays at initial stages of disease and absence of an opportunity of realization of expensive methods of research. The introduction of algorithms of diagnostics and realization of additional diagnostic methods has allowed lowering the given parameter on 12 %.

Important parameter of quality of work of a reception is the satisfaction of patients by the rendered medical aid. At realization of sociological interrogation of the patients of a reception is established, that the timeliness and quality of rendering of medical aid by a brigade of first aid satisfies 99,1 % of the patients delivered in hospital. All patients specify, that the brigade of first aid has arrived to them during 1 hour from the moment of a call, from them 67,2 % of the respondents have noted, that the brigade of first aid has arrived to them during 30 minutes. As have noted 61,5 % of the respondents, the doctors of the first help have assisted on " a high professional level ", 37,5 % interrogated are satisfied with work of first aid and 3 patients (0,9 %) in the questionnaire have noted the column "unsatisfactorily".

At interrogation of the patients concerning work of a reception of opinion of the respondents were divided. So, interrogated from 1 group, at which is not revealed pathologies, are satisfied with quality of rendering of medical aid in reception rest only in 74 % of cases. The patients 2 groups, at which the not emergency pathology is revealed, and sent on out-patient inspection and treatment, the quantity(amount) of the satisfied patients much below and has made 58,8 %. Among hospitalized patients 3 groups on 95,7 % of the respondents are satisfied with job of a reception.

The absolute majority of the patients (84,5 %) have noted, that have leadin a reception from 30 minutes till 1 hour, 11,8 % of the patients more than 1 hour and 3,6 % of the patients from 15 about 30 minutes. Analyzing the factors rendering influence on opinion the respondents, came to the conclusion, that the basic influence renders the fact of hospitalization, which is final result. If to the patients refused in hospitalization (interrogated from 1 and 2 groups) owing to absence of an emergency pathology, percent (interest) of unsatisfactory results is higher. In group of hospitalized patients 96 % are satisfied with job of a reception. To a lesser degree render influence volume of the carried spent diagnostic procedures, time carried spent in a reception and age of the patients. The quantity interrogated, dissatisfied job of a reception is more in age group is more senior than 50 years.

Discussion of the received results. Having analyses the received data, we came to the conclusion, that the basic loading on a filtration of the patients is assigned to job of brigades of first aid, that requires from them high qualification. The increase of not profile calls of first aid testifies about weak development of prophylactic medical examination of the patients and primary medicine-sanitary service. The substantial growth of quantity cured of cases in hospitals of city Astana specifies centralization of the patients from regions and testifies to the large authority of metropolitan clinics.

For an estimation of quality of job of a reception of clinics rendering medical aid by the patient with an emergency pathology, the indicators of an estimation of an overall performance are necessary. As such indicators it is offered to estimate time of stay of the patient in a reception, divergence of the preliminary and clinical diagnoses, repeated reference of the patients with the subsequent hospitalization and satisfaction of patients.

The analysis of results the questionnaire of the patients has shown, that the satisfaction of the patients by job both first aid, and reception, in the greater degree depends not on a general condition both of conducted methods of diagnostics and treatment, but on the fact of whether hospitalization them in hospital or not.

Literature.

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3 Luchkevich V.S. Basis of social medicine and management of public health services, St.-Petersburg, 1997ã. - 184 p.

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