Reform of emergency (emergency) medical care in Ukraine since 2016

Paramedics in Texas

There are two main systems of emergency medical care in the world:

• German-French, where emergency medical care at the prehospital stage is provided by doctors,
• Anglo-American, where help is provided by emergency medical equipment of various levels, including paramedics. ^[2]

Often in most countries, to ensure effective pre-hospital care, while remaining within the budget and the capacity of the existing infrastructure, compromise decisions are made. ^[2] In the countries where these models come from, they have changed towards efficient medical care.

In several US states, physicians may travel to certain severe cases. ^[2] Emergency doctors specializing in air emergency medical care in the UK ^{[3] [4]} and Australia ^[5] .

In Germany, doctors now leave for not all calls. Part of the calls can be fully serviced only by the German equivalent of paramedics ( German Rettungsassistent ), in other cases the doctor comes separately, provides only advice or assistance, and the patient is transported by a team without a doctor. ^[2]

Ambulance car, modification UAZ-3962.

In Ukraine, about a third of emergency medical teams are lacking ^{[6] [7]} . Many doctors of pre-retirement age. At the same time, few young doctors come to work in this industry. ^{[6] [8]} Part of the vehicles are understaffed. Also missing are the cars themselves. ^[9] Transportation and medical equipment are on average 60-70% obsolete, physically worn and need to be replaced. ^[10] In some teams, staff work without proper education, in particular, a nurse. ^[eleven]

50 years ago there was a similar problem in the USA . ^{[12] The} National Academy of Sciences of the USA in 1966 released the report “Accidental Death and Disability: Rejected Diseases of Modern Society” (“White Book”), which is considered to be a guideline in the development of the system of emergency medical care in the USA. According to him, the standards by which emergency medical services worked were different and often “low”; “Most ambulances used in this country are unfit, have incomplete ... equipment, inadequate supplies, and are also serviced by inexperienced workers.” ^[13]
This report led to the development and implementation of the first emergency medical services and personnel, the requirements for which were determined at the federal level. The reforms initiated by the publication of this White Paper contributed to the fact that paramedics and emergency medical equipment began to provide quality assistance both at the scene of the incident and during transportation. ^[14]

Active reforming of emergency medical care started after the appointment of the head of the Ministry of Health Uliana Suprun . The main directions of the reform are:

• improving the training of non-medical workers;
• standardization of medical care on the principle of evidence-based medicine;
• introduction of EMT and paramedics;
• staff training in accordance with new programs;
• improvement of work of dispatching;
• the creation of emergency departments. ^[ten]

The reform of emergency medical care is provided for by the medium-term plan of priority actions of the government until 2020, approved by order of the Cabinet of Ministers of Ukraine of April 3, 2017 No. 275-p. ^[ten]

To improve survival from preventive causes of death, help should be as close as possible to the sick or injured person. It is necessary to strengthen the whole chain of survival. Ukraine has the following levels of prehospital care:

• persons obliged to provide domestic medical assistance (analogue of the international term “ Emergency medical responder ” ^[15] );
• emergency medical equipment;
• paramedics ;
• emergency medicine doctors. ^[sixteen]

According to the Law of Ukraine “On Emergency Medical Aid”, the persons who are obliged to provide pre-medical care to a person in emergency condition are:

• emergency rescue services;
• state fire brigade employees;
• police, pharmaceutical workers;
• passenger car conductors;
• flight attendants;
• other persons who do not have medical education, but in their official duties must possess practical skills in the provision of home health care. ^{[16] [17]}

Also, in accordance with Article 18 of the Law of Ukraine “On the National Police”, the police are obliged to provide urgent, in particular, pre-medical and medical, assistance to persons injured as a result of offenses, accidents, as well as to persons who are in a helpless state or condition life or health. ^[18]

The procedure for the preparation of persons who are obliged to provide domestic medical care is determined by the Resolution of the Cabinet of Ministers of Ukraine No. 1115 of November 21, 2012. ^[19]

The Order of the Ministry of Health of Ukraine dated March 29, 2017 No. 346 “On Improving Training in the Provision of Domestic Medical Aid to Persons without Medical Education” approved new training programs for the preparation of such persons. ^{[20] [21] [22]}

Also, the Ministry of Health of Ukraine introduced two new specialty instructors for teaching help skills:

• prehospital care instructor,
• first aid instructor. ^[23]

This will standardize the teaching of appropriate levels of assistance and reach more people with training.

To effectively assist the Ministry of Health also changes the composition of the car first aid kit . In Ukraine, about 554 accidents occur on the roads every day. Mortality is higher here than in other European countries. ^[24] At the same time, the composition of first-aid kits has not changed for 20 years. ^{[25] The} list of new first-aid kits is compiled in accordance with European experience. The necessary minimum includes only the means that can help save the lives of victims. It is forbidden to supplement the first-aid kits with their own medicines. ^[25]

New clinical protocols

The study of the Office of Effective Regulation showed that the Ukrainian information field is littered - about 35% of the acts are outdated, irrelevant and ineffective. ^[26]

On April 28, 2017, the Order of the Ministry of Health of Ukraine No. 1422 dated December 29, 2016 came into force. It allows Ukrainian doctors to use international clinical protocols in their work and, accordingly, to provide assistance according to international standards. ^{[27] [28] [29]} To this, clinical protocols were developed based on the adaptation methodology of international clinical guidelines. Since 2012, only 123 unified protocols have been created. In some cases, they were developed based on the clinical experience of the group members. Their part is created on the old evidence base. In addition, Ukrainian standardized clinical protocols may contain trade names of certain drugs. This led to lobbying by the relevant pharmacological companies. ^[thirty]

This order also abolished the need to implement local clinical protocols. ^[26] Previously, each medical institution was forced to develop such documents. Often they were based on sources of information of various prescription and on the clinical experience of the developer. ^[26] Legally, they were significantly more significant than any world recommendations. The Ministry of Health has allowed each institution to translate international protocols based on evidence-based medicine . ^[27] It identified a clear list of international sources for such translation and approval. ^[28]

HeRAMS Ukraine

Since autumn 2017, WHO, in collaboration with the Ministry of Health of Ukraine, has launched the project HeRAMS Ukraine . ^[31]

HeRAMS ( English Health Resources Availability Mapping System ) is an electronic system for monitoring medical resources. It is a WHO tool for standardizing and assessing the availability of medical services in different countries. It is used to develop emergency response options. In a certain area, information is collected in four main areas: health facilities, resources for providing services, availability of medical services in certain areas, reasons for the lack of medical services. On the basis of the obtained data, analytical reports are made and possible measures are being developed to improve the situation. Periodic monitoring is possible. ^{[32] [33]}

The system was tested and it performed well in Sudan , ^{[34] [35]} Central African Republic , ^{[36] [37]} Fiji , ^[38] Mali , ^[39] Nigeria , the Philippines , the Syrian Arab Republic and Yemen . ^[32] Thanks to her, health care managers were able to assess available resources and guide actions in the right direction.

At first, the assessment will be carried out only on the territory of Donetsk and Lugansk regions. ^{[31] [40]}

Military Emergency Medicine

On January 5, 2017, the Ministry of Health Order No. 6 approved a modern military first aid kit, military automotive first aid kit, and backpacks for orderlies and sanitary instructors. Their composition meets the standards of developed countries, including NATO. With these tools, a soldier can help with frequent emergency situations. ^{[41] [42]} They are primarily aimed at getting rid of those causes of death that can be prevented.

Other

Also important are the development and creation of standards for instructor centers, the creation of a system of accreditation of these centers, and certification of instructors for home health care. ^[ten]

On the recommendation of the World Health Organization, Ukraine is implementing a system close to the Anglo-American system of emergency medical care. In 2017, the Ministry of Health of Ukraine introduced two specialties - a paramedic and emergency medical equipment.

A paramedic is a person with an education level not lower than the junior bachelor of the “Healthcare” field of knowledge and the corresponding specialization ^[23] (the term of study is 3 years for persons with complete secondary education, 4 - with incomplete ^{[23] [42]} ). Qualification requirements for a paramedic are higher than for a paramedic. The paramedics training program is more focused on providing emergency medical care. They have more advanced requirements for professional skills in this area. From September 2018, the first recruitment for this specialty begins in medical schools. ^[42]

The introduction of paramedics concerns only paramedics from the emergency (ambulance) brigades. At FAPs ( feldsher-midwifery centers ) or in other places, the paramedic continues to work. ^[42]

Emergency medical equipment will eventually be replaced by ambulance drivers. ^[6] In terms of length of study and skills, the specialty corresponds to the EMT-B level common in many countries. ^{[15] [43] [44]} Minimum requirements for emergency medical equipment in Ukraine:

• complete secondary education and training in the specialty "Emergency Medical Technician";
• a certificate of completion of training in the training program in the profession "Emergency Medical Technician";
• driver's license of the appropriate category for driving. ^[23]

Paramedics working in emergency medical teams will be able to become paramedics, having gone through advanced training to the level of paramedics. To undergo training and certification of paramedics of emergency medical care to the level of paramedics, drivers - to the level of emergency medical technicians, the Ministry of Healthcare defined a transitional 5-year period. By this time they can work in the brigade. ^{[42] [45]}

Emergency drivers after completing the training will be able to continue to work as emergency medical technicians. However, the emergency medical technician will have the appropriate skills to assist paramedics in assisting. ^[23]

Doctors of medicine of non-equilibrium states will also work in the brigades for the transition period. To obtain a specialist certificate, a doctor should study for 6 years in a medical school and 1.5 years to undergo an internship. However, at the moment doctors often go to calls that do not meet their high qualifications. After the end of the transition period, doctors will be attracted only to certain severe cases, as is the case in many developed countries. ^{[3] [4] [5]} Most of them will go to work in the emergency department of medical institutions. ^[46] There the doctor has more opportunities to use his knowledge and skills. ^[42]

With the participation of British and American doctors, a program of a six-day training course “Supporting life during trauma. Ukrainian program " . It is designed to improve the qualifications of doctors who provide emergency medical care to the injured: surgeons , anesthetists , orthopedic and trauma surgeons, emergency medicine doctors, etc. ^{[47] [48]}

The program takes into account the basic requirements of the relevant international counterparts, such as "PHTLS", "ALS", "ATLS". ^[47] The course consists of seminars, practical stations and simulations. It is intended to systematize the approach to the injured, to work out teamwork and effective communication skills. ^{[49] [50]}

In October 2017 at the meeting of the Academic Council of the National Medical Academy of Postgraduate Education named after P.L. Shupik discussed and approved the curriculum and program of the on-site training cycle of thematic improvement: “Support for life during an injury. Ukrainian program. ^[47]

In most regions of Ukraine, calls are received at emergency stations of a particular region and coordinate the brigades of their station only. In some areas, calls are made by doctors or junior nurses. ^[11] Accordingly, if there is even an emergency vehicle in the neighboring area near the scene of the accident, he will not go there. Centralized dispatch stations that took calls and coordinated the brigades of the entire region are only in a few areas ( Dnipropetrovsk , Kharkiv region and Kherson region ) and Kiev . ^{[10] [46]}

With the introduction of modern centralized dispatch calls, specially trained dispatchers in the regional center will receive calls. Dispatchers determine the need for departure based on dispatch protocols. Also, all emergency medical vehicles are equipped with GPS trackers. Using a modern system will also allow you to track the call. According to the dispatcher, on the interactive map, the dispatcher will see the location of all brigades in real time and the location of calls. He will be able to send the nearest brigade to the sick or injured person, regardless of which station she belongs to. ^{[11] [51]} This will allow providing timely medical assistance even with limited resources.

The emergency department (eng. Emergency department, ED) is a department of the hospital where it is given assistance in case of emergency in patients with diseases and injuries. They are delivered by emergency medical teams or they turn themselves. Therefore, the department is located on the first or another easily accessible floor of a medical institution.

The emergency rooms have beds for assistance and observation. The patient may stay a certain limited period of time. Usually up to 24 hours. In the case when the state is critical, vital functions are stabilized in the resuscitation zone (English Resuscitation area). After it is transferred to the operating room or intensive care unit (intensive care). If the assistance can be fully provided in the emergency room, the patient is discharged home. Otherwise, he is transferred to another department of the hospital or another medical institution.

This department should be distinguished from the reception departments, where there are usually no beds for patients and often there are no conditions for providing quality care. ^[52] There may not be a doctor in emergency departments, or alternate alternately doctors of different specialties. In the emergency departments work specially trained doctors. Usually these are doctors of emergency medicine (emergency medicine) or doctors of other specialties who have passed the relevant specialization. ^[42]

According to health care reform, the availability of an emergency department should be the standard for a multidisciplinary hospital, where assistance is provided in case of non-visible cases. This will bring quality care to the patient. Emergency physicians should work in these departments. So they can better use their knowledge and skills to help patients. ^[42]

Regarding emergency assistance in the media, appearances periodically appear against the Ministry of Health of Ukraine. The main complaints relate to several issues. ^[53]

Больше всего критики касается идеи заменить фельдшеров на парамедиков. ^[54] При этом СМИ указывают на различную продолжительность их обучения - от нескольких месяцев до полугода. ^[54] Проблема заключается в том, что термин «парамедик» в различных странах соответствует разному квалификационному уровню. ^[2] В зависимости от страны или региона в ее пределах, срок обучения лиц, которых называют парамедиками, колеблется от 4 лет до нескольких месяцев. ^{[2] [55] [56]}
На Украине парамедик - это медицинский работник с высшим образованием по степени ниже младшего бакалавра в области знаний «Здравоохранение». Срок обучения в медицинском колледже продолжается не менее 3 лет с особым вниманием на оказании медицинской помощи в системе экстренной помощи. ^{[57] [58]}

В 2017 году СМИ распространяли новости об увольнении всех фельдшеров скорой помощи. ^[59] Однако фельдшеры и водители скорой помощи смогут в дальнейшем работать в составе бригад в течение переходного 5-летнего периода. За это время фельдшеры должны пройти многомесячные курсы повышения квалификации, а водители - нескольконедельные. ^{[42] [57] [59]} Врачи и в дальнейшем будут привлекаться к отдельным вызовам. ^{[42] [45]}

В конца 2017 года года также в отдельных СМИ появились сообщения, что скорая не будет выезжать на вызовы относительно сердечных приступов и очень высокой температуры у детей. ^{[60] [61]}
Согласно законодательству, обращение к экстренной помощи делятся на экстренные (угрожающих жизни) и неекстреные. ^[62] На экстренные вызовы должны выезжать бригады экстренной (скорой) медицинской помощи, а на неекстрени - служба неотложной помощи (при поликлинических учреждениях, т. Н. «Неотложка»). ^{[63] [64]} В случае, если служба неотложной помощи не может принять вызов, диспетчер направляет к пациенту бригаду экстренной (скорой) медицинской помощи, не занята на момент вызова экстренных случаях (например, ДТП, инсульт, преждевременные роды). ^{[62] [63]} То есть в любом случае больной получит надлежащую медицинскую помощь у себя дома или, в случае необходимости, будет госпитализирован в учреждение здравоохранения. ^[64]

• Парамедик