OVERVIEW OF ORGANIZATIONAL STRUCTURE OF EMERGENCY MEDICAL SERVICES IN SERBIA-
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
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-
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-
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 -
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
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-
The paper is part of a broader research and analysis of the condition and availability of pre-
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-
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-
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) -
GROUP II -
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 -
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-
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-
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-
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.
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Jasmina TANASIĆ, PhD
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