1.  86 cities  Up to 500 km away from a microregion headquarters  8 microregions  Area: 122,176 Km² (São Paulo: 1,523 Km²)  Population: 1,558,610 (São Paulo: 10,990,249 inhabitants)  Population density: 12.6 inhab./km² (São Paulo: 7,216 inhabitants/km²) Case Study Emergency/Urgent Care Network Northern Minas Gerais Macroregion

2. Indicator: Years of Life Lost (YLL) > 1 year The leading causes of YLL among the population over 1 year of age are external causes and cardiovascular disease, which together account for more than 46% of this indicator. YLL Rate > 1 year External causes Cardiovascular disease NeoplasmsOther diseases of the circulatory system Source: SIM/DATASUS Diseases of the respiratory tract Infectious/parasitic disease OthersDiabetes mellitusDiseases of the digestive tract

3. 10 Leading causes of years of life lost (YLL) in Minas Gerais, 2004-2006 DISEASE YLL (thousands) % % (cumulative ) Rate Ischemic heart disease 1589.2 8.2 Cerebrovascular disease 1448.417.67.5 Acts of violence 1116.524.15.8 Traffic accidents 865.029.14.5 Lower respiratory tract infections 684.033.03.5 Hypertension 633.736.73.3 Diabetes mellitus 593.540.23.1 Asphyxiation/birth injuries 573.343.53.0 Cirrhosis of the liver 563.346.82.9 Inflammatory heart disease 432.549.32.2

4. Hospital-Based Emergency Care: At the Breaking Point http:/www.nap.edu/catalog/11621.html

5. Source: Hospital-Based Emergency Care at braking point Institute of Medicine of the national academies - 2007

6. 1.Correctly direct the patient… 2.… to the appropriate level of care 3.…that can provide the most effective treatment 4.…as fast as possible.

8. Economies of scale Availability of resources Quality Access

9. PRIMARY CARE Call centers Health posts (unidade basica de saúde – UBS) Charity or small-scale hospitals (hospitais filantrópicos e de pequeno porte [HF/HPP]). Local small-scale hospitals perform a vital role within the network when access to higher- complexity services are located more than one hour away. MEDIUM COMPLEXITY Urgent Care Units (Unidades de Pronto Atendimento – UPA) Microregional hospitals – these must be accessible to at least 100,000 inhabitants, some of which should provide care for more complex traumas or stabilize such patients Emergency Mobile Care Unit (Serviço de Atendimento Móvel de Urgência – SAMU) TERTIARY LEVEL Macroregional hospitals with specialized services in line with preestablished parameters Trauma Referral Hospitals – must be located within access to at least 1 million inhabitants Hospital Referral/ CV; 400mil pop. Rehabilitation Hospitals SAMU Health posts or UBS are the local care centers Microregional/macroregional hospitals (former: more complex trauma)

10. NUMBERNAMECOLORTIME TARGET 1EmergencyRed0 2Very urgentOrange10 3UrgentYellow60 4Somewhat urgentGreen120 5Non-urgentBlue240 White: patients whose condition does not merit emergency/urgent care

11. DETERMINANTRISK CLASSIFICATION APPROPRIATE NETWORK SERVICE POINT IDEAL TREATMENT TIMEFRAME Adult abdominal pain Microregional or macroregional hospital * Treat immediately In remote areas, transfer within at least 30 minutes Adult abdominal painMicroregional hospital ** Treat within no more than 10 minutes Transfer within no more than 30 minutes Adult abdominal pain Microregional hospital or HPP * ** Treat within 60 minutes. Same-day transfer (24 hours) Adult abdominal painHPP or UBS Treat within 120 minutes Adult abdominal painHPP, UBS, or residence Treat within 240 minutes (no more than 24 hours)

12. MAJOR TRAUMA CARE NETWORK RESOURCES HOSPITAL LEVEL 1LEVEL 2LEVEL 3 Neurosurgery Vascular surgery Angiography Upon notification: thoracic, cardiac, pediatric, plastic, maxillofacial, and implant surgery Heliport with exclusive access Emergency room (Mobile Medical and Basic Support Units) High-complexity operating room Computerized tomography Trauma surgeon Orthopedist Emergency room physician General surgeon Anesthesiologist Transfusion unit Intensive care unit

13.  Step 1. Perform a situation analysis of the emergency/urgent care (EUC) network  Step 2. Select the model of care for the EUC network  Step 3. Develop the health districts and levels of the EUC network  Step 4. Design the EUC network  Step 5. Build the primary care component of the EUC network  Step 6. Build the secondary and tertiary care levels of EUC network  Step 7. Design network support systems  Step 8. Design network logistical systems  Step 9. Establish oversight systems for the EUC networks THE ROAD AHEAD STEPS FOR STRUCTURING THE EMERGENCY/URGENT CARE SERVICES NETWORK

14. Mobile Medical Unit (MMU) Basic Support Unit (BSU) Advanced Support Unit (ASU) Command Center Air Transport Unit (ATU)

15. Macrohospital Microhospital Level III Microhospital Small-scale hospital São João do Paraíso Urucuia São Romão Monte Azul Manga Verdelândia Rio Pardo de Minas Januária Microhospital Salinas Microhospital Bocaiuva Microhospital Pirapora Microlevel III Trauma Hospital Brasília de Minas Microlevel III Trauma Hospital Janaúba Microlevel III Trauma Hospital MOC Macrolevel I Trauma and Cardiac Hospital, Santa Casa MOC Macrolevel I Trauma Hospital, Clemente Faria MOC Macrolevel II Cardiology Hospital, Aroldo Tourinho Taiobeiras Microlevel III Trauma Hospital Fundação Dilson Godinho Coração de Jesus Francisco Sá

16. R$ 75,000.00 Level I Cardiology Hospital R$ 50,000.00Level II Cardiology Hospital - R$ 320,000.00 Level I Trauma and Cardiology Hospital R$ 210,000.00Level II Trauma and Cardiology Hospital R$ 130,000.00Level III Trauma and Cardiology Hospital R$ 250,000.00 Level I Trauma Hospital R$ 180,000.00 Level II Trauma Hospital R$ 130,000.00 Level III Trauma Hospital R$ 100,000.00 Microregion R$ 20,000.00Basic Hospitals/Level

17. COMMAND CENTER

18. Results Short-Term Evaluation Process: - Progressive increase in system use: Calls to Call Center (Jan. 1,742; Aug. 7,882) Pre-hospital ambulance trips (Jan. 883; Aug: 2,904) Clinical Management: - Shorter decision-making time: critical for the outcome in the U/E - 50% drop in microregional hospital patients in green and blue risk categories: integration of primary care, and Manchester Protocol implemented throughout the network - Clinical reports

19. Recapping...  E mergency care systems should be based on a regional model  Emergency care systems should be under a single authority and their different points of service delivery should be coordinated  Patient flows between points of service delivery and logistics should be based on risk classification  Results of the system must be monitored  System planning and preparations are required to address sudden increases in its use  Oversight is needed to enforce rules (outsourcing) and monitor results  A new financing model is necessary, based on the adjustment of goals (replacing the fee-for-service model)

20. Recapping... Thank you! Antônio Jorge de Souza Marques