Emergency Medicine Reform in Ukraine since 2016

Emergency Medicine Reform in Ukraine is a part of Ukrainian Health Reform from 2016 till now. It consist of measures of the Ministry of Healthcare of Ukraine to provide high-quality and timely emergency medical care.[1]

General information

Ukraine has a German-Franco Model of Emergency Medical Service, in which an ambulance is staffed by physicians. A part of ambulances are staffed by feldshers. In Ukraine, about one third of the emergency medical teams are missing.[2][3] Unfortunately young doctors don't eagerly join EMS teams. That is why the majority of doctors are those of pre-retirement age.[4][2] Some ambulances are not fully equipped. Moreover, there is a lack of vehicles.[5] Some brigades have staff without proper education.[6]

UAZ-396295 (it is UAZ-3962 modification). Used in emergency medical services (EMS). Ukraine.

US faced a somewhat similar problem around 50 years ago. United States National Academy of Sciences published an influential report "Accidental Death and Disability: The Neglected Disease of Modern Society" in 1966. It is considered a landmark in the development of the emergency medical services system in the United States.[7] The report concluded, in part, that both the public and government were "insensitive to the magnitude of the problem of accidental death and injury" in the U.S.; that the standards to which ambulance services were held were diverse and "often low"; and that "most ambulances used in this country are unsuitable, have incomplete … equipment, carry inadequate supplies, and are manned by untrained attendants."[8] The reforms inaugurated by the publication of "The White Paper" led to higher quality care provided on-scene and in-transit by trained paramedics and EMTs.

Active reforming of emergency medical care was initiated right after appointment of Ulana Suprun as a head of the Ministry of Healthcare of Ukraine. There are several main areas of this reform.[1]

  • Improvement of non-medical persons training.
  • Standardization of medical care on the principles of evidence-based medicine.
  • Introduction of EMT and paramedics into the Ukrainian emergency medical service system.
  • Training of personnel in accordance with new programs.
  • Improvement of medical dispatching.
  • Introduction of emergency departments.[1]

Improvement of non-medical persons training

In order to improve survival from the preventable causes of death, help should be brought as closer as possible to the patient. It is necessary to strengthen the whole chain of survival. There are several levels of care in pre-hospital care in Ukraine.

Patriot Defence instructors train policemen in emergency care.

According to Ukrainian legislation, there are no official terms "Emergency medical responder" or "First responder".[10] But there is an equivalent – persons, who are obliged to provide emergency medical assistance to a person in urgent need. They are:

  • rescuers of emergency rescue service;
  • state fire brigade workers;
  • police officers;
  • pharmaceutical workers;
  • conductors of passenger trains;
  • flight attendants;
  • other persons who do not have medical education, but in their official duties include practical skills in providing premedical care.[10][11]

In particular after police reform, the National Police officers are obliged to provide emergency medical care to those who have suffered as a result of offenses, accidents, as well as to those who are in a helpless condition or that which can be dangerous to their life or health.[12]

Ministry of Healthcare of Ukraine on March 29, 2017 approved new training programs for the training of such persons, who are obliged to provide emergency medical assistance to a person in urgent need.[13][14]

At the same time MOH of Ukraine introduced two new specialties of medical instructors:

  • Pre-hospital care instructor,
  • First Aid instructor.[15]

This will standardize the teaching of relevant levels of care and attract more people to study.

MOH of Ukraine is currently introducing new demands to be applied to the collection of supplies of vehicle first aid kits. In Ukraine, there are about 554 traffic accidents every day. Mortality is higher here than in other European countries.[16] At the same time, the first-aid kit demands did not change for 20 years.[17] New demands are based on evidence-based medicine and best westert practices. Medical supplies are mostly aimded to prevent most possible cause of death.[17]

Standardization of medical care

New clinical guidelines

The Better Regulation Delivery Office research has shown that the Ukrainian information field is clogged up — about 35% of the acts are obsolete, irrelevant and ineffective.[18]

In April 2017 Ministry of Healthcare allowed Ukrainian doctors to use international clinical guidelines in their work and, so to provide medical care according to world standards.[19][20][21] Prior to this, clinical guidelines were developed based on the method of adaptation of international clinical guidelines. In some cases, they were developed based on the clinical experience of group members. Part of them is created on the old soviet evidence base. In addition, Ukrainian unified clinical guidelines may contain trade names for certain drugs. This led to the lobbying of the relevant pharmacists.[22]

With the same order MOH of UKraine also eliminated the need for the implementation of local clinical protocols.[18] Previously, each medical facility was forced to develop such documents. Often, they were based on sources of information of different antiquity and on the clinical experience of the developer.[18] At the same time, they were legally much more weighty than any world guidelines. MOH has allowed each institution to translate international protocols, based on evidence-based medicine.[19] It defines a clear list of international sources for such translation and approval.[20]

HeRAMS Ukraine

In autumn 2017 World Health Organization, in cooperation with the Ministry of Healthcare of Ukraine, launched the HeRAMS Ukraine project.[23][24]

HeRAMS (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 mostly used for emergency response.[25] When conducting programs using HeRAMS, information is collected from health facilities in a specific area. The system collects information on four major contingencies related to emergencies:

  • health care establishments (number, type ...);
  • resources for the provision of services (water supply, cold chain ...);
  • availability of medical services in certain spheres (emergency medicine at the pre-hospital and hospital stages, trauma care...);
  • the reasons for the lack of medical services (lack of medical staff, poor training ...).

Based on the data obtained, analytical reports are made and possible measures are developed to improve the situation. Periodic monitoring is possible.[25][26]

At first in Ukraine HeRAMS project was launched only in Donetsk and Lugansk regions.[23][24]

Military Emergency Medicine
Compiling of military first aid kits by Patriot Defence volunteers for ukrainian soldiers in the Eastern Ukraine. 2015.
Volunteer military IFAKs.

In January 2017 MOH of Ukraine approved a modern military first aid kit, a military car first aid and backpacks for field medics. Their composition is developed in accordance with the Tactical Combat Casualty Care guidelines.[27][28] With these means, the soldier can provide casualty care in the most frequent emergency situations. They are primarily aimed at salvation from the causes of death that can be prevented.

MOH of Ukraine, together with the Ministry of Defense of Ukraine, worked out the standards of medical support of the Armed Forces at the level except big hospitals. Specialists have excluded drugs that have no proven efficiency. Each medical facility or military unit will have the same equipment and medicine, so it will be able to provide high-quality medical care.[28][29]

There is a lack of medical staff in the majority of hospitals in Lugansk and Donetsk region.[30] To improve the situation, medical volunteers from other regions are allowed by MOH order to go and work there.[31][32] This will help to save not only health and lives of local people, but also soldiers, who are also often treated in these hospitals.[30]

Introduction of EMT and paramedics

In 2017 MOH of Ukraine introduced two specialties —- paramedics and emergency medical technicians.[15]

Paramedic

In Ukraine paramedic is a person with a level of education not lower than a junior bachelor of the field of knowledge "Healthcare" and the corresponding specialization. This means that after 11 years of school, in order to become a paramedic, he needs to study for another 3 years. For a person with basic 9-year education, the term of training will be 4 years.[28][15]

In Ukraine paramedics provide an ALS level of care. Qualifying requirements for paramedic are higher than those for a feldsher. The paramedic training program is more focused on providing emergency medical care. They have more advanced requirements for professional skills in this area. In September 2018, there will be the first set for this specialty in medical colleges.[28]

Feldshers working in the emergency medical teams will be able to become paramedics after undergoing advanced training to paramedic level. The Ministry of Health has defined a transitional period of 5 years for training and certification of emergency medical feldshers to the paramedic level. By this time, they can work as part of the EMS teams.[28][33]

The introduction of paramedics concerns only the emergency teams. Feldsher will continue to work in feldsher-obstetrician stations in rural areas.[28]

During the transition period emergency medicine physicians will still work in ambulances. However, at the moment, physicians often go to simple cases that do not meet their high qualifications. At the end of the transition period, physicians will be engaged only in some severe cases, as it is in many developed countries.[34][35][36] Most of them will get a job in the emergency departments.[37] There, physicians have more opportunities to use their knowledge and skills.

Emergency medical technician

Now in Ukraine ambulances are driven by ambulance drivers. But as in many countries in the past, in Ukraine these employees are not trained in emergency care. That is why new specialty of emergency medical technician was introduced. Ambulance drivers will continue to work during a 5-year transition period. During this time, everyone should be trained and certified for the level of emergency medical technician.[28]

New emergency medical technician profession corresponds to EMT-Basic in USA. In Ukraine EMT according to the assigned duties:

  • works under the guidance of a physician or paramedic;
  • provides care in the EMS team;
  • assists the emergency department staff;
  • interacts with other medical services;
  • evaluates the environment regarding possible threats to him or other people;
  • participates in the triage;
  • assesses the patient's condition;
  • examines the patient for urgent conditions;
  • conducts CPR;
  • provides care in case of adverse reactions to medicines;
  • assists in transporting patients and transpors patients to health care facilities;
  • provides basic medical support during mass events, sports events, other events;
  • drives ambulance, supports it in a state of readiness, etc.[15]

The minimum requirements for emergency medical technician in Ukraine are:

  • full secondary education and training by specialty "Emergency medical technician";
  • the presence of a certificate of training in the program for the profession "Emergency medical technician";
  • a driver's license for the relevant category for driving.[15]

Term of training to become EMT lasts about a month, which includes studying in classes and practical training of skills.[38][28]

New training programs for emergency staff
Teaching modern principles of trauma care. Photo by Patriot Defence.

With the participation of British and American physician, a six-day training course "Ukrainian Trauma Life Support" (UTLS) was developed. It is intended for the upgrading of doctors providing emergency medical care to the injured patients: surgeons, anesthesiologists, traumatologists, emergency medicine doctors, etc.[39][40]

The program takes into account the main requirements of the relevant international counterparts, such as "PHTLS", "ALS", "ATLS".[39] The course consists of seminars, workshops and simulations. It is intended to systematize the approach to the injured, to work out team work and skills of effective communication.[41][42]

In October 2017, at the NMAPE Academic Council meeting was discussed and approved the curriculum and the program of the on-site training cycle of thematic improvement: "Supporting life during injuries. Ukrainian program».[39]

Improvement of medical dispatching

In most oblasts of Ukraine, raions or city has its own emergency medical dispatch center. They coordinate teams only of their own station and in usual situation send them only to their area of their responsibility. So, if accident takes place near the "border" of neighboring area, the dispatcher won't be able to see it. Consequently, he won't be able to send an ambulance for help, even if a few are located close nearby. In some raions, calls are taken by doctors or nontrained nurses.[6] Centralized dispatch centers which take calls and coordinate EMS teams of the entire oblast exist only in several regional centers.[37]

With the introduction of modern centralized dispatch centers, specially trained dispatchers in the oblast level will take calls from all the region. Using the dispatch protocols, a dispatcher will determine if there is an urgent necessity to send an ambulance or not. Also, all ambulances will be equipped with GPS trackers. Using the modern system will allow to track the call location. So, the dispatcher will see the location of all places of call and EMS teams in real time on the interactive map. He will be able to direct the nearest crew to the patient or victim, regardless of which station it belongs to.[6][43] This will allow to provide timely medical care even with limited resources.

Introduction of emergency departments

An emergency department (ED) is a medical treatment facility specializing in emergency medicine, the acute care of patients who present without prior appointment; either by their own means or by that of an ambulance. The emergency department is usually found in a hospital or other primary care center.

Currently, most hospitals in Ukraine have reception departments (Ukrainian: приймальне відділення, IPA: [ˈprɪjmɐlʲne wiˈd⁽ʲ⁾ːilenʲːɐ]). There are usually no beds for patients' stay and often there are no conditions for providing high quality care. Often there is no physician for full day or in different days there are on duty physicians from different specialities, who can not provide proper emergency care.[44]

According to the Healthcare Reform, an emergency department should be a standard for a multi-profile hospital, which provides care in the case of emergency. Only specially trained doctors of emergency medicine will work in ED. So they can better use their knowledge and skills to help patients. It will also help to bring qualitative care to the patient.[28]

See also

References
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  2. Emergency medical care reform: how to get into the patient for 8 minutes on YouTube 5 Kanal (Ukraine), Interview with Tetyana Timoshenko, 20.04.2017
  3. "Kyiv is acutely lacking in doctors" (in Ukrainian). Sogodni. March 23, 2016. Retrieved January 13, 2018.
  4. Emergency medical care reform: how to get into the patient for 8 minutes on YouTube 5 Kanal (Ukraine), Interview with Alima Gordiychuk, 20.04.2017
  5. "Not everyone will survive in the ambulance" (in Ukrainian). rionews.com.ua. August 24, 2012. Retrieved January 13, 2018.
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  8. Division of Medical Sciences, Committee on Trauma and Committee on Shock (September 1966), Accidental Death and Disability: The Neglected Disease of Modern Society, Washington, D.C.: National Academy of Sciences-National Research Council
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