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The implementation of the Medical Regulation Office and Mobile Emergency Attendance System and its impact on the gravity profile of non-traumatic afflictions treated in a University Hospital: a research study
© Lopes et al; licensee BioMed Central Ltd. 2007
Received: 13 December 2006
Accepted: 24 October 2007
Published: 24 October 2007
The public health system of Brazil is structured by a network of increasing complexity, but the low resolution of emergency care at pre-hospital units and the lack of organization of patient flow overloaded the hospitals, mainly the ones of higher complexity. The knowledge of this phenomenon induced Ribeirão Preto to implement the Medical Regulation Office and the Mobile Emergency Attendance System. The objective of this study was to analyze the impact of these services on the gravity profile of non-traumatic afflictions in a University Hospital.
The study conducted a retrospective analysis of the medical records of 906 patients older than 13 years of age who entered the Emergency Care Unit of the Hospital of the University of São Paulo School of Medicine at Ribeirão Preto. All presented acute non-traumatic afflictions and were admitted to the Internal Medicine, Surgery or Neurology Departments during two study periods: May 1996 (prior to) and May 2001 (after the implementation of the Medical Regulation Office and Mobile Emergency Attendance System). Demographics and mortality risk levels calculated by Acute Physiology and Chronic Health Evaluation II (APACHE II) were determined.
From 1996 to 2001, the mean age increased from 49 ± 0.9 to 52 ± 0.9 (P = 0.021), as did the percentage of co-morbidities, from 66.6 to 77.0 (P = 0.0001), the number of in-hospital complications from 260 to 284 (P = 0.0001), the mean calculated APACHE II mortality risk increased from 12.0 ± 0.5 to 14.8 ± 0.6 (P = 0.0008) and mortality rate from 6.1 to 12.2 (P = 0.002). The differences were more significant for patients admitted to the Internal Medicine Department.
The implementation of the Medical Regulation and Mobile Emergency Attendance System contributed to directing patients with higher gravity scores to the Emergency Care Unit, demonstrating the potential of these services for hierarchical structuring of pre-hospital networks and referrals.
The Unified Health System of Brazil, instituted in 1988, is organized into a network of increasing complexity, with integrated, regionalized hierarchies that ensure that the principles of equity in access to health resources, universality and integration of care are guaranteed for all citizens [1–3]. However, these legal measures have failed to provide solutions for daily hardships, especially within the emergency care system [4, 5].
With the clear expansion of primary care and pre-hospital emergency care, which has occurred with international financial help, the general clinical attendance and emergency care management continue to be centralized in hospitals designed to guarantee first aid to patients presenting acute diseases of all levels of severity, creating excessive demands on hospitals of greater complexity located in large urban centers such as the city of Ribeirão Preto .
Ribeirão Preto is a city of 504,923 inhabitants, 72% of them depend on public health care . The primary care network is structured into 32 basic units and 5 family health units. The city counts, too, with 13 specialized ambulatory units, 5 of them designed for emergency care. The hospital network consists of 4 general hospitals and 1 obstetric hospital, with a total of 1115 beds offered to the public health system. Due to its affiliation with the University of São Paulo School of Medicine at Ribeirão Preto, the University Hospital is a reference center for a population of more than five million from five districts of São Paulo . It has 761 beds distributed between the University Campus Unit (with 604 beds for elective admissions) and the Emergency Center (EC) downtown (with 157 beds for emergency admissions, being 43 for critical care ).
The Mobile Emergency Attendance System (SAMU), which was instituted in 1996, includes one advanced mobile emergency unit, staffed by doctors and nurses, and 12 basic mobile emergency units, staffed by professionals trained in basic life support. In an attempt to organize the health services in a hierarchical manner and to guarantee the management of patient flow within the emergency care system, the Medical Regulation Office (MRO) was instituted in 2000, in a process which considered the experiences of similar systems in place in North America and Europe [7–12]. The office began to regulate the flow of emergency cases to the hospitals, with popular support, respecting the hierarchical position of each institution and the actual level of care available at the various health care centers.
From this perspective, the objective of this study was to analyze the impact of these services on the gravity profile of non-traumatic affections at the EC.
The study, conducted after being approved by our Ethics committee, involved 906 patients older than 13 years of age (patients younger than that age were generally cared for by pediatricians) who presented non-traumatic afflictions and were admitted to the EC in the areas of Internal Medicine, Surgery and Neurology during two different one-month periods: May 1996 (474 patients) and May 2001 (432 patients). The first study period (May 1996) was chosen because it preceded the creation of the SAMU and its MRO. At the time of the second study period (May 2001), the SAMU and MRO had been fully operational for at least one year.
The populations studied during the two cited periods were analyzed in terms of general demographic data, origin, presence or absence of other medical affections besides the principal diagnosis (co-morbidities) and in-hospital complications (any secondary diagnosis that appeared during the hospital stay, reflecting an organic affliction other than the principal diagnosis).
The Student's t-test was used to determine the statistical significance of the differences between means. For statistical analysis, the programs Microsoft Excel 2003 (Microsoft, Seattle, WA, USA) and Minitab, 13th version (Minitab Inc., State College, PA, USA) were used. For ROC curve analysis, the SPSS 13.0 for Windows (SPSS inc., Chicago, Illinois, USA) was used. For multiple logistic regression analysis, the SAS 9.0 (SAS Institute Inc, Cary, NC, USA) was used. The level of statistical significance was set at P < 0.05.
Demographic characteristics of the study population
49.0 ± 0.9
52.0 ± 0.9
50.0 ± 1.3
52.0 ± 1.2
47.0 ± 1.9
49.0 ± 2.2
49.0 ± 1.8
57.0 ± 2.3
2. Distribution by age bracket
13 |- 20
20 |- 30
30 |- 40
40 |- 50
50 |- 60
60 |- 70
70 |- 80
80 |- 90
Ribeirão Preto (city)
Ribeirão Preto (region)
Evolution of distributions according to specialty, percentage of complications, mean mortality rate and presence of co-morbidities
1. Clinical areas
2. Mortality rate observed (%)*
3. Presence of co-morbidities (%)
4. Percentage of complications observed during the hospital stay
APACHE II mortality risk in the study periods
Overall (mean ± sd)
12.0 ± 0.5
14.8 ± 0.6
Internal medicine (mean ± sd)
11.5 ± 0.6
15.3 ± 0.8
Surgery (mean ± sd)
13.9 ± 1.1
14.7 ± 1.2
Neurology (mean ± sd)
11.5 ± 0.6
15.3 ± 0.8
The MRO was implemented to manage patient flow between the network of health services, thus matching patient need for care with the service complexity and capacity of the respective hospital units. The impact on the health care indicators for the EC was immediate, and those indicators have fluctuated little over the recent years. Between the years 1996 and 2001 the number of consultations was reduced from 139,137 to 50,214 and admissions fell from 19,511 to 11,927, while the occupancy rates fell from 104.6% to 88.4% . The observed data, in association with the increase in mortality risk based on the APACHE II score, demonstrate the technical and management capacity of the MRO in ordering healthcare access within the University Hospital, as well as in directing the less serious afflictions to other centers of the emergency network
Initially, health managers believed that the MRO and SAMU services would bring about a reduction in emergency-room admissions of low severity cases, but that the severity profile of the patients admitted would not be affected. However, after the operation of MRO, the health care teams had the perception that the hospital had begun to receive a larger number of elderly patients with higher incidences of co-morbidity and, consequently, higher incidences of complications during the hospital stay and higher mortality risk, mainly in the Internal Medicine Department. This study has confirmed the perception of health care teams and has shown that the joint work of MRO and SAMU, in addition to redirecting the low severity cases for lower complexity emergency care centers, extended the access of critical care to patients from the reference centers, contributing to the consolidation of the principle of equity.
The evolution observed in the pattern of hospitalization and in the severity profiles mirrors the changing demographic and epidemiologic profiles of populations in other developed and developing regions, including Brazil. However, the relative age increase of about three years of the patients admitted in May of 2001, when compared with the admitted ones in May of 1996, placed patients above the average age of the Brazilian population between these two periods by about eight months .
It is important to emphasize that, beyond the role of the SAMU and MRO in organizing access to the network of emergency services, the perceived and confirmed results induced the managers of the university hospital, as well as those responsible for the municipal and regional public health system and for the University, to adopt new strategies for teaching and practicing emergency care.
These results induced the health managers of the EC to reorient the internal spaces. Among the 16 beds of the emergency room, 5 were transformed into beds of clinical stabilization. Among the 108 beds assigned to the ward of internal medicine, neurology and surgery, 10 have been transformed into a unit of intermediate care and 10 into an isolation unit for contagious diseases. There was an increase in the number of intensive care beds for adult patients (from 7 to 16). The University of São Paulo School of Medicine at Ribeirão Preto, despite a good deal of resistance on the part of its directors, has increasingly shifted its academic activities, and even its research activities, from the University Hospital to the network of primary and secondary care facilities . The managers of the public health system and the academy are learning that it is no longer possible to provide all levels of health care at a tertiary-care hospital.
On the basis of the data analyzed and the evaluation system adopted, we conclude that the medical regulation of the flow of patients and the control of the dispatch of mobile resources have contributed to the increased severity profile of patients presenting with non-traumatic emergencies to the Internal Medicine Department of the Emergency Care Unit. This process, despite the conflict observed between professionals, managers of the public health system and the academy, gained popular support and induced the internal reorganization of the hospital with an increase in the number of intensive care beds, and promoted the replacement of didactic and medical assistance activities in a non-hospital unit for emergency care, forcing the primary and secondary levels of care to assist in low complexity emergencies, referring only the more complex ones to the tertiary level of care.
- BRASIL. Presidência da República. Constituição da República Federativa do Brasil. Diário Oficial [da] República Federativa do Brasil, Brasília, DF. 1988, [http://cff.org.br/constituicao.htm]
- BRASIL. Lei no 8080/90, de 19 de setembro de 1990. 1990, [http://www.cff.org.br/legis/leis%5Clei_8080_90.html]
- BRASIL. Lei no 8142/90, de 28 de dezembro de 1990. 1990, [http://www.cff.org.br/legis/leis%5Clei_8142_90.html]
- Santos JS, Scarpelini S, Brasileiro SLL, Ferraz CA, Dallora : Evaluation of the model of organization of Emergency Unit of the University Hospital Faculty of Medicine of Ribeirão Preto, University of São Paulo, based on the national policy of emergency care and humanization as a reference. Medicina, Ribeirão Preto. 2003, 36: 498-515.View ArticleGoogle Scholar
- Tannebaum RD, Arnold JL, De Negri Filho A, Spadoni VS: Emergency medicine in Southern Brazil. Ann Emerg Med. 2001, 37: 223-28. 10.1067/mem.2001.112252.View ArticlePubMedGoogle Scholar
- Instituto brasileiro de geografia e estatística. Censo. 2000, [http://www.ibge.com.br/censo2000.htm]
- Llewellyn CH: The role of telemedicine in disaster medicine. J Med Syst. 1995, 19: 29-34. 10.1007/BF02257188.View ArticlePubMedGoogle Scholar
- Garshnek V, Hassell LH, Davis HQ: Telemedicine: breaking the distance barrier in health care delivery. AIAA Student J. 1997, 35 (1): 2-8.Google Scholar
- Reid FDA, Cook DG, Majeed A: Explaining variation in admission rates between general practices: cross sectional study. BMJ. 1999, 319: 98-103.View ArticlePubMedPubMed CentralGoogle Scholar
- Rosenberg AL, Hofer TP, Hayward RA, Strachan C, Watts CM, Bartlett RH: Admission source predicts surgical CIU outcomes: implications for tertiary referral centers [abstract]. Anesthesiology. 2000, 3A: B7.Google Scholar
- Norwood S, Fernandez L, England J: The early effects of implementing American College of Surgeons Level II criteria on transfer and survival rates at a rurally based community hospital. J Trauma. 1995, 39: 240-245.View ArticlePubMedGoogle Scholar
- Calman K: Developing emergency services in the community. The final report. 1997, London: NHS ExecutiveGoogle Scholar
- Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE: APACHE – acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med. 1981, 9: 591-597.View ArticlePubMedGoogle Scholar
- Knaus WA, Draper EA, Wagner DP, Zimmerman JE: APACHE II – A severity of disease classification system. Crit Care Med. 1985, 13: 818-829. 10.1097/00003246-198510000-00009.View ArticlePubMedGoogle Scholar
- Le Gall JR, Loirat P, Alperovitch A, Glaser P, Granthil C, Mathieu D, Mercier P, Thomas R, Villers D: A simplified acute physiology score for ICU patients. Crit Care Med. 1985, 12 (11): 975-977.View ArticleGoogle Scholar
- Jennett B, Teasdale G, Braakman R, Minderhoud J, Heiden J, Kurze T: Prognosis of patients with severe head injury. Neurosurgery. 1979, 4 (4): 283-289. 10.1097/00006123-197904000-00001.View ArticlePubMedGoogle Scholar
- Keene AR, Cullen DJ: Therapeutic Intervention Scoring System: update 1983. Crit Care Med. 1983, 11: 1-3. 10.1097/00003246-198301000-00001.View ArticlePubMedGoogle Scholar
- Knaus WA, Le Gall JR, Wagner DP, Draper EA, Loirat P, Campos RA, Cullen DJ, Kohles MK, Glaser P, Granthil C, Mercier P, Nicolas F, Nikki P, Shin B, Snyder JV, Wattel F, Zimmerman JE: A comparison of intensive care in the U.S.A and France. Lancet. 1982, 2: 642-646. 10.1016/S0140-6736(82)92748-9.View ArticlePubMedGoogle Scholar
- Beck DH, Smith GB, Taylor BL: The impact of low-risk intensive care unit admissions on mortality probabilities by SAPS II, APACHE II and APACHE III. Anaesthesia. 2002, 57: 21-6. 10.1046/j.1365-2044.2002.02362.x.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/7/173/prepub
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