UDK 614.88(497.11)
ISSN 2466-2992 (Online) (2020) br.1-2, p. 17-26
COBISS.SR-ID 46884105
OVERVIEW OF ORGANIZATIONAL STRUCTURE OF EMERGENCY MEDICAL SERVICES IN SERBIA- PERSPECTIVE OF LOCAL SELF- GOVERNMENT
Jasmina Tanasić1, Miljan Jović2, Nataša Ločkić3, Siniša Saravolac4, Saša Ignjatijević5, Tatjana Rajković5, Snežana Holcer Vukelić6, Kornelija Jaksić Horvat7, Jelena Đukić Perović8
1Standing Conference Of Towns And Municipalities,Belgrade, Serbia, 2 Emergency Department Zaječar, Serbia, 3Institute for Public Health „Milan Jovanovic Batut“,Serbia, 4 Institute for EMS Novi Sad, Serbia, 5 Institute for EMS Niš, Serbia, 6Emergency Department, General Hospital Sombor, Serbia, 7Health Centre Subotica, Serbia, 8 Business Associate, Siemens Healthineers POC testing, Eurodijagnostika, Novi Sad
Summary:
INTRODUCTION: The legal and strategic framework for HMP in Serbia does not exist as a separate one, but within the umbrella laws and strategies in the area of health care. The criterion for the existence of an organizational unit of EMS in the city/municipality is 25,000 inhabitants, which is every second municipality in Serbia. Cities and municipalities have competencies for financing emergency medical care, but there are no norms and no bylaws have been adopted that specify these competencies of local self-government units. Serbia is facing the reform of the EMS, everything is still functioning according to the old rules, and is uneven. Small and underdeveloped municipalities (under 25,000 inhabitants) are in a particularly unfavorable position, as they do not meet the criteria for establishing a special organizational unit of the EMS.
METHODS AND MATERIAL: Situation analysis, qualitative and applied research were conducted during 2018 by the SCTM with the aim of mapping the availability and condition of prehospital EMS with recommendations for improvement. An expert team was established, a questionnaire was developed, which was filled out by health institutions in the period from August 1-15, 2018, and a database was formed. A total of 145 LSG completed the questionnaire. Focus group meeting was held on September 14, 2018 in Belgrade (MoH, Republic Commission for Emergency Medicine, expert team, WG of the Committee on Health and Social Policy of the SCTM). The results of the research were presented and conclusions and recommendations were adopted by consensus, and they were supported and adopted by the Presidency of SCTM.
RESULTS: Organizational structure of the EMS: I Group 4 LSGs (4 EMS Institutes: Belgrade, Nis, Novi Sad and Kragujevac) 3.25% of the territory and 29.08% of the population; II LSG group - HC with organizational unit of EMS - 70 LSG, 47.38% of the territory and 49.21% of the population; III Group: (less than 25,000 inhabitants): 75 LSG, 13.14% of the population in 33.57% of the territory of RS. Of which: III/a LSG group (EMS within Adult Health Care at HC - duty teams) 11.6% of the territory and 5.04% of the population; and III/b health centers in which EMS services are provided through the regular operation of the general medicine service cover 22.41% of the territory and 8.10% of the population.
DISCUSSION: The availability and state of EMS provision in Serbia is not uniform. Institutes are the best organized, although they are the most burdened, and the more the organizational form is "drowned" in primary health care, the worse is the situation and the lower the availability of EMS. It is necessary to develop a strategic and legal framework for the EMS and start the reform. Small, underdeveloped and fragmented, and border municipalities are in a particularly difficult position.
Key words: emergency medical service, organisational model, mulicipality
INTRODUCTION
The emergency medical service (hereinafter: EMS) in Serbia is organizationally related mainly to the primary level of health care, as an integral part of the Health Center, and a smaller part is related to other levels of health care: EMS institutes and the Emergency Center. The Law on Health Care of the Republic of Serbia (2019) envisages a change in the organizational structure of the network of primary health care institutions, as well as the establishment of regional centers for EMS with unique dispatch centers at the district level. The legal and strategic framework for EMS does not exist as a separate one, but is within the framework of umbrella laws and strategies in the field of health care. EMS services are charged from the Republic Health Insurance Fund (RHIF). The criterion for the existence of an organizational unit of the EMS in the city/municipality is 25,000 inhabitants. Cities and municipalities, according to the Law on Health Care, have the authority to finance emergency medical services and increase the availability of primary health care, especially for vulnerable groups, but there are no norms and bylaws that specify these powers of local self-government. Serbia is facing the reform of the EMS, however, in this interspace, everything is still functioning according to the old rules, and it is uneven. Small and underdeveloped municipalities (below 25,000 inhabitants) are in a particularly unfavorable position, as they do not meet the criteria for establishing a special organizational unit of the EMS (service). According to the data from the end of 2015, 87 municipalities (out of a total of 145 local self-government units in Serbia) did not have an emergency medical service as a separate organizational unit . In the meantime, the EMS reform has not taken place, except that the pressure on employees has increased, as evidenced by the data on the work and use of the EMS service in Serbia for 2017 . The report states that every 4th inhabitant of Serbia was examined by the EMS (1,582,098 medical examinations); every 23rd resident was provided with a medical examination at the site of injury and illness (a total of 304,010 field examinations); every 9th child and every 5th adult in the Health Center achieved EMS in the form of the first examination; EMS services at HC covered a total of 38,123,362 km, while at the same time a decrease in medical doctors was noticed compared to 2016.
METHODOLOGY
The paper is part of a broader research and analysis of the condition and availability of pre-hospital emergency medical care and medical transport in Serbia, conducted in 2018 by the Standing Conference of Cities and Municipalities of Serbia. The research is qualitative and applied, it was conducted with the aim of mapping the availability and condition of prehospital EMS. Through research and analysis, the paper examines and maps (among other things) the legal solutions, the existing organizational models and the personnel structure of employees in the EMS. In a broad consultative process and cooperation with all relevant stakeholders, primarily with the Ministry of Health, the SCTM Committee on Health and Social Policy and the SCTM Presidency, appropriate recommendations for further activities have been created.
The research is contextual in terms of features (needs, experiences, relationship between parts of the system); evaluative (status, achievement of EMS goals); diagnostic (causes and reasons of the problems) and strategic (opportunities for improvement and new approaches). An expert team was formed, a questionnaire was developed based on the questionnaires used so far (IPH Batut, questionnaire used in the EU project ). Official data from the 2011 census were used to process the data and interpret the results. The data were analyzed and presented according to the mentioned organizational forms of emergency medical service in health care institutions.
In the part of the research that deals with organizational models of EMS, the answers to the following questions were analyzed: how is EMS organized; how EMS is performed: from several points or one place; number of points from which EMS is performed; organization of working hours; organization of work in shifts; number of shifts working on weekdays (day, night) and weekends and holidays (day, night); the existence of a full EMS team for the infirmary only; number of EMS teams in the clinic; number of ambulance crews per shift; composition of the medical transport team; organizing preparedness in case the team has to leave its territory; average retention of the medical team in higher level centers; average retention of the transport team in higher level centers; data on the territory in which the EMS services are provided (area, widest diameter, maximum distance from the EMS headquarters to the tertiary level of the HC); whether the EMS covers part of the highway; length of highway coverage by EMS services; population of local self-government; seasonal variations in population; the reason for seasonal variations; additional EMS activities (home care, coronation, therapy, dressing in the field); way of performing additional activities (regular composition, out of Alertness).
In the process of data collection, a letter of support for completing the survey was signed by the State Secretary of the Ministry of Health and the Secretary General of the SCTM. The letter was forwarded to the offices of all mayors, with a request to forward it to the relevant health institutions in their territory, in charge of providing EMS (EMS institutes and health centers). The target group in charge of completing the questionnaire were health institutions. The questionnaire was completed in the period from 1-15. August 2018. The questionnaire was completed by a total of 145 LSGs (100%). To finalize the analysis, the project task was achieved through the work of a focus group at a workshop held on September 14, 2018 in Belgrade. Apart from the expert team, the workshop was attended by representatives of the Ministry of Health, the Republic Commission for Emergency Medicine and the WG of the Committee on Health and Social Policy of the SCTM, a total of 30 participants. The results of the research were presented and conclusions and recommendations were made in consensus. The findings and recommendations of the research were presented in May 2019 at the 4th session of the Committee on Health and Social Policy of the SCTM, held in Dimitrovgrad. The Committee supported the conclusions of the Analysis and supported the efforts of the Standing Conference to continue the planned activities in the field of improving the accessibility of EMS, especially in municipalities with less than 25,000 inhabitants. Conclusions and recommendations of the Analysis were presented at the session of the SCTM Presidency in November 2019, which decided that the SCTM should continue with activities related to improving the situation and accessibility of the EMS in the coming period.
RESULTS
The first task in the preparation of the Analysis was also one of the biggest challenges, and it referred to the division of organizational prehospital models according to which the EMS operates in Serbia. The law stipulates that these can be EMS Institutes, EMS services at health centers (for municipalities with more than 25,000 inhabitants) or that EMS is provided through adult health care (with teams, on duty or not). The first two groups were not questionable. The problem arose in defining the third group. After the first workshop, with the presence and cooperation of all stakeholders, in April 2018, a consensus was reached that organizational models for research purposes correspond to reality, and were divided into 3 groups, with the third group divided into two subgroups.
GROUP I: includes 4 cities (Belgrade, Novi Sad, Kragujevac, Nis) 3.25% of the territory and 29.08% of the population. Belgrade is specific, since the peripheral city municipalities (Obrenovac, Barajevo, Grocka, Lazarevac, Mladenovac, Obrenovac, Sopot) have EMS services at their health centers, and the rest are covered by the Institute. The distance between the two most distant points at all four Institutes is the same (70 km), the proximity of secondary and tertiary institutions is the same (up to 10 km), and also all 4 Institutes cover parts of highways. All Institutes (except Kragujevac) operate organizationally from several points. All four Institutes have the same work schedule (in shifts: Day shift (12h) - 24h free - Night shift (12h) - 72h free). The average retention of the team during the transfer of the patient to other institutions is similar (5-20 minutes). The transport of an urgent patient is performed by a complete team. They have a smaller number of teams for transport at night, except in IEMS Kragujevac, which does not have a transport team at night. No Institute performs home care or coroner's duties. IEMS Nis performs home visits in the area of field service, Kragujevac stated examinations in closed institutions and IEMS Novi Sad stated urgent transport. Serious differences in the organizational part are reflected in the schedule of field teams for day and night, as well as in the number of ambulance teams. The composition of transport teams also differs. The teams consisting of a nurse/technician/driver have IEMS Belgrade and Novi Sad, while IEMS Kragujevac and Nis have only a driver.
GROUP II - EMS service in Health Centers exists in 70 cities and municipalities; covers 47.38% of the territory and 49.21% of the population. Out of a total of 70 IEMS, 58 IEMS responded to the questionnaire. The analysis is based on material of 82.85%. The differences in functioning and organization are greater than in the first group. Demographic data show that EMS services cover a large number of residents in a large area. Geographically, there are large differences in the group itself in area: from Kraljevo with an area of 1530 km2 to Temerin 170 km2. There are also big differences in the number of inhabitants (Leskovac with 144,206 inhabitants and Majdanpek: 18,616). When it comes to the distance between the two endpoints, the situation is also very different. Distance of 100-150 km: 6 IEMS (10.34%) (Čačak, G. Milanovac, Kraljevo, Majdanpek, Trstenik, Valjevo). Distance of 50-99 km have 32 IEMS (55.17%). 20 IEMS have the distance of 20-49 km (34.48%). IEMS Kraljevo has the longest distance (150 km) and IEMS Temerin has the shortest distance (20 km). In organizational terms, the largest percentage of IEMS operate from one place in (89.66%) and these are smaller LSGs. Where IEMS operate with more points (10.34%) are cities with a larger area and a larger number of inhabitants, except for Majdanpek, where it can be explained by a large area. The exception is Indjija, where IEMS operates from several points, regardless of the average area and number of inhabitants (below 50,000) - there are many larger cities with a larger area and they do not operate from more points. The largest percentage of IEMSs work in shifts like the institutes (56.89%). Some kind of shift - work in shifts of 12 hours is represented in about 29.31% of IEMS. A completely unclear work schedule is stated in 7 large cities (Čačak, Leskovac and Kruševac - over 110,000 inhabitants and local self-government units with a large area) as well as Ivanjica, Priboj, G Milanovac and Vrnjačka Banja (from 27-45,000 inhabitants). The evenly distributed number of teams for day and night on weekdays, weekends and holidays is at 91.37% of IEMS. Slightly more than half of IEMSs (60.34%) have the same number of medical teams (weekdays/weekends, night and day), and 15.51% do not have a medical team (neither on weekdays nor on holidays - day and night). About 12.06% of IEMS do not have an outpatient clinic during the day (weekdays and weekends) and they have one at night. There are daily transport crews during the whole week only in 35.04 LSGs. Transport teams consist of drivers by composition in half of the cases (53.44%), while in 27.58% they are drivers with a nurse/technician. Alertness does not exist in 50% of IEMS, while in 32.75% it exists for the whole team. The team for transport of urgent patients is formed in 62.02% from shifts and in 31.08% it comes from home, while in 4 IEMS it is formed from doctors and n/t from the outpatient clinic (6.89). Every second IEMS on average does not perform additional tasks (55.18%).
III GROUP of LGS: EMS within the Adult Health Care at the Health Center. Out of 75 HC, 62 HC filled in the questionnaires and the analysis is based on material of 82.66%. This organizational model covers from 13.14% of the population to 33.57% of the territory of RS.
This group is divided into two subgroups of respondents:
III/a GROUP: EMS within the Adult Health Care of HC - on-duty teams) includes 18 local self-government units; 11.6% of the territory and 5.04% of the population.
III/b group of LSGs: Health centers in which EMS services are provided through regular work of the general medicine service include 44 LSGs; 22.41% of the territory and 8.10% of the population.
Demographic data show that the third group mainly includes cities and municipalities with a smaller number of inhabitants in a relatively large territory (13.14% of the population of RS to 33.57 %% of the territory of RS). Geographically, there are large differences in the group itself in the area (Sjenica with 1059 km2 and Lapovo with 55 km2). There are also big differences in the number of inhabitants (Sremska Mitrovica with 79,940 inhabitants and Trgoviste with about 5,000 inhabitants). The highest average distance (43 km) between two points in Subgroup A has almost 95% of local self-government units (Tutin with 105 km). Subgroup B has an average distance of 78 km between the most distant points of about 43.18%. The rest of the HC (about 56%) have a distance difference of 35km. The ways of organizing EMS are the same and refer to both subgroups (A and B). Mostly everyone works from one place (95%). Also, 95% of LSGs in both subgroups have the same number of field teams in relation to day/night as the working day/weekend code for both groups. In 50% of cases in both subgroups the transport team consists of driver and a nurse/technician. Alertness does not exist in 40% in both subgroups. The emergency patient transport team is formed in 50% from the shift in subgroup A, and 44% in subgroup B. The teams that perform the work of the EMS do not perform the tasks of home care or coronation in 55.18%. Subgroup A is organized through shifts of 12 hours in 78%, while subgroup B has shifts of 12 and 8 hours (70%). Subgroup A does not have an outpatient team in 44.44%, while Subgroup B has an outpatient team in 90% (this is logical, since EMS is provided during the work of doctors in the outpatient clinic). Both subgroups distributed the number of outpatient teams (working day/weekend, night and day) in the same way in 60.34%. The number of transport teams is represented in subgroup A in 66.7% cases, and in subgroup B in 95%. Attention should be paid to the fact that in subgroup B, 22.5% stated "other" in the transport team. Alertness for the whole team is 50% in subgroup A, and only 29.5% in subgroup B. In subgroup A, all LSGs have a distance of 20-50 km to the secondary institution (100%), and in subgroup B 70%. The distance to tertiary institutions more than 50 km in subgroup A is 16% and in subgroup B 25%. Detention at the tertiary level is longer in subgroup B. In subgroup A, 80% do not perform additional activities, while in subgroup B this case is in 20% of local self-government units.
DISCUSSION AND CONCLUSIONS
The aim of this analysis was to map the condition and availability of prehospital emergency medical care in Serbia. After the research, the results showed that neither the condition nor the availability of pre-hospital emergency medical care are the same in Serbia, neither for patients nor for the providers of this service, i.e. health care institutions and workers. The analysis showed that the EMS Institutes function most evenly, although they are very loaded. The situation is a bit worse in the Health Centers with the EMS service. The worst situation and availability are in 75 surveyed municipalities with less than 25,000 inhabitants and in which EMS is provided within the adult health care service or through the EMS organizational unit through the regular work of the general medicine service. This logic follows all the examined indicators.
The analysis expressed the needs of all examined EMS groups for standardization of this area. Everyone agrees that one of the most important conditions is the existence of a legal and accompanying bylaw framework that would regulate this area in a unique way. Emergency medical service works according to the principles of risk management and crisis management, and the existence of norms, rules and procedures is indispensable. Also, it has been shown that efficient and effective provision of EMS becomes more problematic when the service itself is less autonomous, i.e. the more organizationally "sinks" into the primary level of health care. The biggest problem is how to organize the care of emergency cases in municipalities with a smaller number of inhabitants than 25,000 (14% of the population, 35% of the territory of Serbia), because according to current norms they do not have enough staff to organize an independent organizational unit EMS (IEMS). By organizing the provision of EMS in this way, the availability of primary health care is reduced, since the same staff performs both services, which is physically impossible.
The Law on Health Care (2019) envisages the establishment of a regional network of EMS centers, with a joint dispatch center. The new law also envisages the obligation of local self-government units to finance the functioning of the EMS on their territory. This solution does not guarantee an efficiently set EMS, especially without funding criteria and norms for the functioning of the EMS. Funding the operation of EMS by the local self-government should be planned, continuously, based on evidence, with monitoring of the EMS's performance indicators, workload, condition of equipment and vehicles and working conditions. Therefore, regular cooperation and coordination of EMS services and health institutions with the competent local self-government bodies and the health council is an important condition for prioritization in financing by local self-government. In addition, small and underdeveloped, as well as border municipalities are particularly problematic when it comes to this topic. They need a special kind of support to make the EMS available to their residents under similar conditions as in other environments. Leaving these municipalities to deal with the problems of the functioning of the EMS on their territory is too much of a burden. This category of local self-governments needs special support from the state in order to improve the capacity and availability of EMS. Without standardizing the conditions for work in the provision of pre-hospital EMS, local self-government units will not be able to respond in the right way to the obligations arising from the new Law on Health Care, which obliges them to finance the functioning of EMS on their territory. This is not the best solution, as the analysis has clearly shown that the smaller and poorer the municipality is, the worse and less accessible the conditions are for providing EMS. This brings us back to the topic of future reform envisaged by the new legal solutions and the possible consideration of the idea that the EMS will be financed from the state budget in the future, and not from the funds of the RHIF. The conclusion of the Presidency and the Committee on Health and Social Policy of the SCTM is that well-organized and efficient work of emergency medical service must not be the privilege of large cities, but must constantly improve and harmonize with the needs of the population and the situation on the ground, so that every citizen on the territory of RS could have equal chance to receive adequate emergency medical service, in case of need and all in accordance with modern medical principles. The right to life must not be a privilege of urban and developed environments. Therefore, financing the functioning of the EMS in small and underdeveloped municipalities must not be left to the ad hoc burden of local self-governments. On the contrary, these municipalities especially need support so that emergency medical services in their territories can be efficient and accessible to everyone and in all conditions.
For all the above reasons, it is necessary to make an additional effort to enter the reform of the EMS as soon as possible, which is envisaged by the new Law on Health Care, where the organization of the EMS would be approached in a unique way.
LITERATURE
1. Uredba o Planu mreže zdravstvenih ustanova i Organizaciona struktura zdravstvenih ustanova u Republici Srbiji (presek 31.12.2015.), Institut za javno zdravlje Srbije ''Dr Milan Jovanović Batut''.
2. Analiza primarne zdravstvene zaštite u Republici Srbiji za 2017. Institut za javno zdravlje „Milan Jovanović Batut“,
http://www.batut.org.rs/download/publikacije/Analiza%20PZZ%202017.pdf
3. Standard Summary Project Fiche – IPA centralised programmes
https://ec.europa.eu/neighbourhood-enlargement/sites/near/files/pdf/serbia/ipa/paramedics_en.pdf
4. M. Sjeničić, W. Tiede, “Comparative Analysis of the Serbian and European Legislation on Emergency Medical Services with Special Regard to Inconsistencies and Gaps in the Serbian Legislation“.
5. Dr. Goran Stojiljkovic, ZHMN (2012): Regionalization of EMC in Serbia, Symposium of Emergency Medicine, Belgrade.
6. Regulation on the Plan of the Network of Healthcare Institutions and the Organizational Structure of Healthcare Institutions in the Republic of Serbia (section 31/12/2015), Institute of Public Health of Serbia ''Dr Milan Jovanovic Batut''.
7. Analysis of primary health care in the Republic of Serbia for 2017. Institute of Public Health "Milan Jovanovic Batut",
http://www.batut.org.rs/download/publikacije/Analiza%20PZZ%202017.pdf
Korespondencija/Correspondence
Jasmina TANASIĆ, PhD
Department for Social Affairs
Secretary of the Health and Social Policy Committee
Standing Conference of Towns and Municipalities
Makedonska 22, 11000 Beograd
E-mail. jasmina.tanasic@skgo.org
Phone. +381 (11) 3223446
Fax. +381 (11) 3221215
Cel. +381 (64) 8703315
