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МИНИСТЕРСТВО ЗДРАВООХРАНЕНИЯ РЕСПУБЛИКИ БЕЛАРУСЬ УЧРЕЖДЕНИЕ ОБРАЗОВАНИЯ «ГОМЕЛЬСКИЙ ГОСУДАРСТВЕННЫЙ МЕДИЦИНСКИЙ УНИВЕРСИТЕТ» Кафедра общественного здоровья и здравоохранения
ОБЩЕСТВЕННОЕ ЗДОРОВЬЕ
И ЗДРАВООХРАНЕНИЕ
Учебно-методическое пособие для студентов 4–6 курсов факультета по подготовке специалистов для зарубежных стран, обучающихся по специальности «Лечебное дело» медицинских вузов
THE PUBLIC HEALS
AND HEALTH CARE
The educational methodical work for 4 th , 5 th and 6 th year students of the Faculty on preparation of experts for foreign countries, specialty of «General medicine» of medical higher educational institutions Гомель ГомГМУ
УДК 614.2(072)=
ББК 51.1(2Англ)я О- 28 Авторы: Л. Г. Соболева, Т. М. Шаршакова, Е. Р. Линкевич, Н. Г. Скоромный Рецензенты: кандидат медицинских наук, доцент, проректор по лечебной работе Гомельского государственного медицинского университета Д. Ю. Рузанов ; заведующий научно-исследовательским сектором Гомельского государственного медицинского университета И. А. Чешик Общественное здоровье и здравоохранение : учеб.-метод. пособие для О-28 студентов 4–6 курсов факультета по подготовке специалистов для зарубежных стран, обучающихся по специальности «Лечебное дело» медицинских вузов = The public heals and health care: the educational methodical work for 4th, 5th^ and 6th^ year students of the Faculty on preparation of experts for foreign countries, specialty of «General medicine» of medical higher educational institutions / Л. Г. Соболева [и др.]. — Гомель: ГомГМУ, 2013. — 76 с. ISBN 978-985-506-519- Предназначено для проведения занятий на кафедре общественного здоровья и здравоохранения с целью получения знаний, умений и навыков. Cодержит современные материалы по общественному здоровью и здравоохранению. Соответствует учебному плану и типовой учебной программе по дисциплине «Общественное здоровье и здравоохранение», утвержденной Министерством здравоохранения Республики Беларусь. Предназначено для студентов 4–6 курсов факультета по подготовке специалистов для зарубежных стран, обучающихся по специальности «Лечебное дело» медицинских вузов. Утверждено и рекомендовано к изданию Центральным учебным научно- методическим советом учреждения образования «Гомельский государственный медицинский университет» 1 февраля 2013 г., протокол № 1. УДК 614.2(072)= ББК 51.1(2Англ)я
5. RENDERING OF OBSTETRIC-GYNECOLOGIC CARE
FOR WOMEN...................................................................................................
5.1. The multilevel system of rendering of perinatal care........................... 35 5.2. Organization of outpatient and obstetric-gynecologic care for rural residents in outpatient clinics of general practice, rural medical stations and obstetric stations.............................................................................. 38 5.3. Antenatal clinic..................................................................................... 41 5.4. Analysis of the antenatal clinic work (characteristics)......................... ............................................................................................................................. 45 5.5. Organization of hospital medical care in maternity health organization............................................................................................. 49 5.6 Organization of maternity hospital work............................................... 49 5.7. Analysis of the maternity hospital work............................................... 51
6. STATE SANITARY-EPIDEMIOLOGICAL SERVICE IN THE REPUBLIC OF BELARUS............................................................... 52 6.1. The sources of origin............................................................................ ............................................................................................................................. 52 6.2. The main tasks of state sanitary-epidemiological service.................... 53 6.3. Bodies and institutions, carrying out the state sanitary supervision................ 53 6.4. The structure of the center of hygiene epidemiology and public health................................................................................................. 54 6.5. Interaction of the center of hygiene epidemiology with medical prophylactic centers and other organizations...................................................... 55 6.6. The performance of social –hygienic monitoring................................ 55 6.7. The organization of work of the specialists forming healthy lifestyle............................................................................................................... 56 6.8. Methods, ways and types of hygienic education and upbringing............. 57 7. TASKS FOR STUDENTS’ SELF WORK.......................................... 58 7.1. Topic: «Municipal polyclinic» ............................................................ 58 7.2. Topic: «Hospital» ................................................................................ 59 7.3. Topic: «Organization of emergency medical aid»............................... 62 7.4. Topic: «Rendering of obstetric-gynecologic care for women»............ 62 8. TEST CONTROL.................................................................................. 63 8.1. Topic: «Municipal polyclinic»............................................................. 63 8.2. Topic: «Hospital»................................................................................. 66 8.3. Topic: «The organization of medical service for rural population»........... 68 8.4. Topic: «State sanitary-epidemiological service in the republic of Belarus. Оrganization of specialists on healthy lifestyle».............................. 69 Supplement 1 .............................................................................................. 72
Supplement 2 .............................................................................................. 73 Literature.................................................................................................... 74 INTRODUCTION The medical care in a hospital is of great importance in preserving and restoring of health. It rendered at the most serious diseases that require an integrated approach to diagnosis and treatment, the use of complex methods of examination and treatment, constant medical supervision and intensive care. The knowledge of the issues of organization, planning, analysis and evaluation of this type of care provides an efficient and effective use of hospital beds in hospitals, to determine the development of hospital replacing forms for the rendering of therapeutic and preventive care. Technical progress, the development of industry, transport, technicalization of all the parts of human’s life make background of the growth of accidents, traumas, intoxications, mass catastrophes. The demand in medical aid increases, because of the growth of emergency conditions of elderly and old people and also of children and teenagers. These are the conditions of necessity of development of emergency service medical aid. Outpatients’ clinic aid in its contents, meaning and volumes has a special place in health system in the Republic of Belarus. Being the main link of primary health care outpatients’ clinic aid is also the most mass and available type of prophylactic aid and treatment. Considering rather low cost of outpatients’ clinic aid and prophylactic orientation the development of this type, unlike hospital care and emergency service, is a priority in modern conditions of reforming the health systems. CHE and PH control sanitary conditions, providing antiepidemic routine of work of every MPC (polyclinics, dispensaries, hospitals, MSP, outpatients clinics and etc). CHE and PH controls the performing of all the measures to detect infectious patients, their hospitalization, mass health examination, isolation, the completeness of prophylactic vaccination of population; it
medical rehabilitation of sick and disabled.
- implementation of work on public hygienic education. Approximate organization structure of a municipal polyclinic:
- The management of polyclinic.
- Registry.
- Prophylactic department.
- Treatment and prophylactic subdivisions are: physicians’ rooms, procedure units, surgeries, urologist’s room, traumatic surgeon’s room, otolaryngologists’ rooms, neurologist’s, cardiologist’s, endocrinologist’s room; department of medical rehabilitation (room of physiotherapy, acupuncture, logopedist, physical therapy room, day hospital).
- Antenatal clinic (obstetric-gynecologic department).
- Auxiliary-diagnostic subdivisions (Clinical — diagnostic laboratory, radiology department, X-ray room, x-ray room, ultrasound room, functional diagnostics department (room), endoscopic room).
- Centralized sterilization.
- Medical statistics room.
- Administrative and economic part (accounting, personnel department, lawyer’s office, civil defense engineer’s office, labour protection and safety engineer’s office, record-keeping office). Management of the polyclinic consists of the head doctor and his deputies, head nurse. Registry in polyclinic provides the management of the flows of people in the polyclinic, storing and giving out medical information about the patient in the form of «medical card» or information received in the result of computerized record. Immediate reception managing is done by the head reception nurse. The main tasks of polyclinic reception are:
- providing prerecord and emergency records of patients to doctors, both in presence or by the phone;
- providing accurate regulation of the intensity of streams of patients in order to create equal work load for doctors and to divide it into the types of provided help;
- providing opportune selection and delivery of medical documentation into doctors’ rooms, correct keeping and saving card file of polyclinic. Prophylactic department consists of : preliminary examination room; room for patients' examination (masculine and feminine); anamnestic room; organization and control of public prophylactic medical examination office including keeping centralized card file of patients observed by a specialized clinic; creating healthy lifestyle room; vaccination room;
profpathologist’s room. The main tasks of prophylactic department are:
- organization of early diagnostics of sick and people at risk;
- organization and carrying out preliminary and periodic examinations;
- organization and control of public prophylactic medical examination;
- organization and control of carrying out prophylactic vaccination for teenagers and adults;
- the development of plans of action for primary and secondary prevention of diseases on the territory of the services of polyclinics;
- managing of work on propaganda of sanitation knowledge among population, creating healthy lifestyle and fight with unhealthy habits. The leading organization principle, on the base of which the activity of polyclinic is built is local ― territorial principle. All the served area is divided into the districts, each district has a district physician. According to state social standards one district doctor has to serve 1700 people of adult population. And with it, the amount of population, attached to a district physician is stated by the head doctor or the head of the department according to standards currently in force and considering age and gender groups, population density, the attendance formed and some other factors. A district physician must provide:
- opportune qualified therapeutic aid to the population of his district in presence or at home;
- case follow-up and active patients’ treatment till their recovery, remission or hospitalization;
- emergency medical care for patients, regardless their residence, in case of their direct visit with acute conditions, traumas, intoxications;
- opportune hospitalization of therapeutic patients with mandatory preliminary examination with planned hospitalization, if necessary providing further out-patient treatment after their discharge from hospital;
- studying the state of the health of served population, detection of people at risk and providing the necessary health promotion programs;
- consulting the patients by the head of therapeutic department or by other specialists from the polyclinic or from other public health organizations, if needed;
- using modern prophylactic, diagnostic and treatment methods in his work, including complex therapy (medications, dietologist, exercise therapy, massage, physiotherapy, etc.);
- organization and carrying out a set of measures on adult public medical organization of the district (detection, registration, case follow-up, health promotion programs); the analysis of effectiveness and quality of medical examination;
- assistance in solving medical and social patients’ problems;
- issuing conclusions to the residents of the served district, who is doing medical examinations and leaving abroad;
The main criteria of the volume of outpatients’ help to population is the number of doctor’s visits in polyclinic and at home. According to the regulations of volumes of medical aid, provided by government-financed organizations in the Republic of Belarus, the regulation of the volume of outpatient’s medical aid is expressed in number of visits outpatients’ polyclinic organizations and visits paid by doctors at patients’ homes there are 10600 visits per 1000 residents. For a district-physician workload in polyclinic is 4,5 visits an hour and it’s about 2 visits an hour at home. 1.2. Public medical examination Public medical examination — is a method of active follow up the health conditions of all the groups of population (healthy, almost healthy, sick). Medical examination of adult population is a system of medical programs, oriented to detect diseases or factors, influencing on their appearance, to assess health level of every Belorussian citizen. This assessment includes:
- medical examination;
- regular medical check-up;
- propaganda of healthy lifestyle, education of having interest and responsibility to one’s health; In the prophylactic department (office) of a public health organization, a medical card of an ambulatory (form № 025/у) and registry form № 131/у — D «Card of regular medical check-up». Groups of case follow up: D (I) — healthy people, who don’t complain about their health level, who doesn’t have any acute, chronic diseases or dysfunctions of organs and body systems in their medical history and also those, who have slight deviations in their level of health (without tendency to progressing), which don’t influence on work capacity; D (II) — almost healthy people, having acute diseases or risk factors of chronic diseases in their medical history; D (III) — people, having chronic diseases with moderate or evident dysfunctions of organs and body systems with periodical exacerbations and degradation, multiplicity of their medical examinations is defined by approximate scheme of case follow up. D (IV) — people, people with disability group. In every case follow up group people with risk factors of certain diseases or exacerbation of already existing diseases should be considered. When defining case follow up group the results of previous check ups could be used including the results of laboratory examinations, clinical and instrument researches, only if they were done nor earlier than 12 months. The doctor from prophylactic department (office) makes the individual programs of risk factor in disease progressing for people in group D (II).
People, who are on the list D (III) and who had some acute diseases, operations, traumas with high-risk and people, who are working in harmful areas, are registered at different doctors — district physicians, doctors — specialists of corresponding field, general practice doctors. Person’s refusal of case follow up is registered in an outpatient medical card (form № 025/у), which is signed by the patient himself and by doctor’s signature of the public health organization. To assess organization and quality of public prophylactic medical examination the following rates are used: Completeness of population coverage with public medical prophylactic examination = number of people, registered in polyclinic at the end of reporting year × 1000 / average annual of attached population. Opportuneness in registering sick people in polyclinic = number of sick registered in medical prophylactic list within a year from the number of newly diagnosed people × 100 / number of new diagnosed people this year. Efficiency of public prophylactic medical examinations = number of sick registered in medical prophylactic list with certain disease with improvement (worsening, without change of condition) at the end of the reporting year × 100 / general number of sick registered in medical prophylactic list with the same certain disease at the end of reporting year. Besides the following final results of prophylactic medical examination can be used:
- People considered healthy (%).
- People transferred from 3 case follow up group to the second one (%).
- People transferred from 2 case follow up group to the first one (%).
- Assessment of changing in condition of the sick according to the criteria: recovery, improvement, without change, worsening, death.
- Assessment of rates, characterizing the quality of performing prophylactic medical examination: observance of periods of check ups, completeness of performance of treatment and health-improvement programs. Also, the efficiency of prophylactic medical examination is characterized by reduction general sickness rate, reduction of the number of cases and days of temporary disability, reduction of statistics of lethality rates, mortality and by reduction of frequency of people registered as disabled among the sick. 1.3. Preliminary medical documents and forms to state statistics reporting of outpatient polyclinic organization To rule an outpatient polyclinic organization, to have efficient and long-term planning, the following information is necessary. One of the source of such information are preliminary medical documents and forms of state and official statistics reporting. All
- training functions (training for medical staff and postgraduate education);
- research functions. The capacity of hospital beds is determined by the absolute number. Depending on the capacity the hospital institutions are divided into the next categories:
1. On the administrative territorial principle: (^) republican; (^) province; (^) municipal; (^) central district; (^) district; (^) divisional hospitals. 2. Depending on the type and nature of medical care: (^) multisectoral; (^) specialized (infectious, tubercular, psychiatric, drug abuse, dermatovenereological, etc.). 3. Depending on the urgency of hospitalization of patients: (^) the hospitals of urgency hospitalization (emergency hospitals); (^) the hospitals for planned hospitalization; (^) the hospitals of mixed type (the most hospitals) where patients come on urgency indications and for a planned hospitalization. 4. According to the system of organization: (^) combined with the clinic; (^) not integrated with the clinic. There are other indications for the classification of hospitals, for example, on the regimen of activity, on the degree of the treatment and care intensity, etc. The order of the Ministry of Health of the Republic of Belarus approved the range of health care institutions where particularly are showed all the possible types of hospitals. The hospital has usually 3 structural subdivisions: management, station, administrative and economic department. At the head of the municipal hospital is a chief doctor responsible for medical-diagnostic, financial, administrative and economic work. The chief doctor has the next deputies on: the medical part (who direct medical diagnostic and sanitary and epidemic hospital work, supervises and who is responsible for the quality of care); the surgical activity (in hospital with the number of beds — 500 and above); the organizational and methodological work. The structure of the hospital include: the reception department. It can be centralized (for all hospitals) and decentralized for its separate main structural parts (example, the hospital reception for infectious diseases, for women in childbirth, etc.);
medical main departments (therapeutic, surgical, neurological, gynecological, etc.); medical subsidiary departments (physiotherapeutic, exercise therapy, radiological, of hyperbaric oxygenation, hemodialysis, etc.); diagnostic departments (laboratories, roentgenologic department, the ultrasound diagnostics department, the department of functional diagnostics, the department of endoscopy, the department of radio-isotopic diagnosis, the department of morbid anatomy); operational unit; pharmacy. The basic structural unit of the hospital is a main department. The hospital department consists of the wards in which there are patients, and subsidiary rooms of medical and household purpose. The capacity of rooms may be different. Advantage should be given to wards with 1–2–3 beds which have a separate sanitary unit (toilet, wash-bowl for hand washing and so on). The administrative household part includes food service sterilization and disinfection service, sanitary technical maintenance of the hospital (water supply, heating and ventilation), transport and other services. 2.2. The primary medical documents and forms of state statistical reports of the hospital For the management of hospital activity, efficient and perspective planning is necessary a proper information. One source of such information are the primary medical documents and forms of governmental and departmental statistical reports. The main forms of primary medical documentation used in hospitals:
- the medical history of hospital patient;
- statistical card of the patient who quitted the hospital;
- the registry of patients reception and refusal in hospitalization;
- the medical card; N the registration paper of the transfusion media;
- the log file of the transfusion media;
- the registry of operative interventions in hospital;
- the paper of main indicators of the patient’s state who was in the intensive care unit;
- the paper of main indicators of the patient’s state who was in the therapy unit of the cardiology department;
- the report of post-mortem examination;
- the paper of registration of patients motion and hospital stock;
- the summary list of patient’s motion registration and hospital stock in the hospital, department or type of beds. The forms of state statistical reports are approved by the proper Decree of the Ministry of Statistics and Analysis of Republic of Belarus and, in general, have an annual periodicity.
- the calculation of the score defective coefficient (SDC) — the sum of defects indices in points;
- the calculation of score normative coefficient (SNC) — the sum of estimations of normative values of effectiveness indices;
- the calculation of the result achievement coefficient (RAC), formulae 1: (1) The coefficient of the result achieving should aim to be towards 1.0 and be above 1.0. The coefficient of the result achieving shows how the activity of estimated institutions corresponds to the requirements demanded to them.
3. THE ORGANIZATION OF MEDICAL SERVICE FOR RURAL POPULATION Among the organizational principles of modern national health one of the important ones is maintenance of medical help unity and succession for urban and rural population. The majority of population lives in rural area. There are 28–30 % of national population living in rural area in the Republic of Belarus. Medical help for rural population is based on the main principles of the organization of public health. Though the factors, which determine the differences between the city and the country influence the organizational forms and mode of operation of rural medical organizations. The main ways of developing medical and sanitary help in rural area:
- Saving united governmental system of public health.
- Improvement of population’s health by the rise of living standard and improvement of environmental conditions.
- Optimization of personnel policy in rural area and elaboration of social development programs and protectability of public health workers. Upgrading of medical and sanitary aid for the purpose of attaching medical workers in rural area, renewing and securing of minimal benefits (free habitation, heating and lighting, upgrading qualification etc.).
- Improvement of work of effective placement mechanism by supporting priority way in the activity of rural organizations of public health (introducing the institution of general practitioners).
- Strict observance of medical and organizational principles of the formation of establishment net in rural area subject to the need of population in medical help and medical and demographic prospects and medical and organizational situation.
- Upgrading the structure and functions of rural medical and prophylactic organizations.
- Assurance of succession in the work of rural local net and specialized services.
- Development of primary accounting and report documentation, expertise of its reasonability.
- Creation of medical and social help establishments (with rehabilitation inclination) for elderly, handicapped and senile people in district hospitals with combined financing of pointed beds by public health and social protection services.
- Widening of medical and social help in outpatient and polyclinic organizations and domiciliary.
- Giving public health system status of basic system which establishes corresponding requirement to another field of national economy by the criteria of their influence on the health of population and assurance of favourable environment. Basic principles of rural public health: Governmental pattern. Smoothness. Free of paying. Accessibility. Prophylactic orientation. Connectivity with science. Participation of the community in health protection. The main task of rural public health is full satisfaction of rural population needs in all fields of medical help. The main peculiarity of organization of medical help for rural population is periodicity of its rendering. The essence of periodicity principle is that on every of following period corresponding medical help is rendered to the patient which couldn’t be provided during the previous period. The peculiarities of rendering medical help to rural population:
- Periodicity.
- Field forms of work.
- Development of general practitioner practice.
- Important role and meaning of paramedical personnel.
- Combining of medical and prophylactic and sanity and antiepidemic measures.
- Development of in-patient department substituting technologies.
- Priority of organizational cooperation with local authorities.
- Development and introduction of telemedicine. Other peculiarities are specified by socio-economic situation and quality of the authority work of all levels of public health. The scheme of organization of medical help for rural population is presented by three stages: I stage. Rural medical area.
- rending medical and prophylactic help for population;
- introduction of modern methods of prophylaxis, diagnostics and treatment during the practice;
- development and improvement of organizational forms and methods of medical service for population, the rise of quality and effectiveness of medical and prophylactic help;
- organization and holding of complex prophylactic measures among the population of the area;
- holding of medical and prophylactic measures for mother and child’s health protection;
- providing research of reasons of common sickness rate and temporal disability diseases and development of measures for its reduction;
- organization and realization of mass health examination, firstly of children and teenagers;
- realization of antiepidemic measures (vaccination, identification of infectious patient, dynamic people observation contacting with them, etc.);
- realization of current sanitary supervision over conditions of working and municipal areas, water supply sources, child care institutions, public nutrition establishments;
- holding of medical and prophylactic measures for tuberculosis control, dermatovenerologic diseases, malignant neoplasms; 11 ) organization and holding of sanitation measures oriented on population development, promotion of healthy life-style including rational nutrition, strengthening of physical activity; fight with alcohol, smoking and other unhealthy habits;
- widespread involvement of the community into the development and holding of public health protection measures. According to these goals rural district doctor’s responsibilities are worked out:
- providing outpatient reception;
- hospital treatment of patients in rural local hospital;
- rendering domiciliary (doctor’s visits at home);
- rendering medical help for acute disease and accidents;
- allocation of patients to other medical departments according to medical indications;
- examination of temporal disability and issuance of disability health certificate;
- organization and providing prophylactic examination;
- opportune clinic registration of patients;
- providing medical and health promotion programs, control of clinical examination;
- active nursing of the pregnant and children;
- providing sanitary and antiepidemic complex programs;
- local sanitary and antiepidemic authorities announcements about
infectious, professional and parasitic diseases, intoxication among population;
- derangements of sanitary and hygienic requirements;
- providing community health;
- sanitary activists trainings;
- organization and providing planned set-offs of doctors to first-aid and obstetrical stations. Special place in local doctor’s professional activity is occupied by the maternity and childhood problems. If there are 2 or more doctors in the local outpatient clinic or local hospital thus by the head doctor’s order one these doctors charges for the children medical service in the area. 3.2. The first-aid and obstetrical stations The first-aid and obstetrical station is a specific peculiarity of rural public health and occupies an important place in rural population medical provision. The first-aid and obstetrical station are outpatient and polyclinic agencies. Their creations are caused by the peculiarities of rural public health, by the necessity of the medical help approximation to population in the wide radius service conditions of the local hospital (outpatient clinic) relative to all the villages. It is organized in the settlements with the population over 700 people and over 5 km away from the nearest medical organization, 300–700 people and over 5 km away or less than 300 people and over 6 km away. The first-aid and obstetrical station goals:
- providing programs which are oriented on prevention and reduction of diseases including infectious diseases; prevention and reduction of parasitic and professional diseases, traumatism and intoxications among population;
- increasing of sanitary and hygienic culture of population;
- rendering first aid, realization of doctor’s prescriptions;
- rendering medical help for acute disease and accidents;
- active nursing of the women; providing community health;
- participation in current medical surveillance over children and teenage departments, municipal, nutritional, industrial and other services, water supply and settlements cleanings;
- providing bypassing the farmsteads according to epidemic demands in order to detect infectious patients, people contacting with them and people suspected of being infected.
- notification of local sanitary and antiepidemic authorities about infectious, professional and parasitic diseases, intoxication among population; derangements of sanitary and hygienic requirements;
- realization of medicine.
