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ARCHITECTURE
UDC 725.51
Bulakh Irina Valerievna
PhD of Architecture, Associate Professor Department of Design of the Architectural Environment, Kiev National University of Construction and Architecture ORCID: 0000-0002-3264-2505; ResearcherID:V-4802-2018; Spin-Kod: 9274-0113; h-index 5
DOI: 10.24411/2520-6990-2019-10040 URBAN NETWORK OF INSTITUTIONS OF THE SECONDARY AND TERTIARY MEDICAL
AID
Abstract.
The article considers and analyzes the existing state of the city-planning network of Ukrainian hospitals. On the basis offoreign tendencies, proposals are being made for the reform of the architectural and urban development network of hospitals with the elimination of excessive specialization characteristic of the territory of Ukraine. The proposed proposals take into account the distribution of Ukrainian hospitals to two levels: the secondary and tertiary level of medical care of the population.
Key words: urban planning system, city planning, network of health care institutions, architecture theory.
Secondary (specialized) medical aid - medical care provided in outpatient or inpatient settings by doctors of specialization (except general practitioners -family physicians) in the planned or emergency cases and provides for counseling, diagnosis, treatment, rehabilitation and prevention of diseases, injuries, poisonings, pathological and physiological (during pregnancy and childbirth) states; referral of a patient according to medical indications for provision of secondary (specialized) medical care from another specialization or tertiary (highly specialized) medical care [1]. Provision of secondary medical care is provided by health facilities:
- in stationary conditions - multi-profile intensive care hospitals, rehabilitation hospital, planned treatment, hospices, medical and social care institutions (nursing care), specialized medical centers;
- in outpatient settings - consultative and diagnostic units of hospitals, medical advisory and diagnostic centers.
Hospitals providing secondary medical care should be divided into five types:
- multidisciplinary intensive care hospital -providing round-the-clock medical care to patients with acute conditions requiring high intensity of treatment and care (myocardial infarction, stroke, acute bleeding, etc.). Resource support of this type of hospitals requires intensive technologies, specialized, diagnostic and medical equipment, availability of resuscitation and intensive care services, and emergency diagnostics;
- hospital for planned treatment of chronic patients - Repeated courses of therapy or treatment using standard treatment regimens, without the need for intensive care and equipment for the treatment procedure;
- rehabilitation hospital - restoration of functions after diseases or injuries, in order to prevent disability and / or rehabilitation of persons with disabilities who require special equipment (physiotherapeutic, simulators for physical therapy, etc.);
- hospices - provision of palliative care and psychological support to terminal (hopeless) patients who need special equipment to provide such care and care, as well as specially trained, mainly nursing staff,
and wide involvement of volunteers;
- hospital for medical and social care (nursing care) - care and provision of social and palliative care to chronic patients with minimal diagnostic and medical equipment, with specially trained mid-level medical staff and social workers.
The current legislation stipulates that secondary medical care may also be provided by physicians conducting economic activities in medical practice as sole proprietors. Similar medical services may be provided in private offices or in communal / private medical centers with the necessary technical equipment [2]. Secondary care is provided free of charge in accordance with the medical certificate in the direction of the primary care physician; a physician from another health care institution providing secondary or tertiary care; obstetrician-gynecologist, dentist, pediatrician; patients with chronic illnesses who are on the dispensary record; Patients in urgent condition. Hospital districts are established in Ukraine in order to ensure the proper quality and availability of free secondary (specialized) medical care and efficient use of health care resources in Ukraine. The procedure for the establishment and urban planning features of the functioning of the hospitals will be considered in the next section of the section. On the basis of the analysis of the current world trends in the organization of the urban development network of secondary medical care institutions in the first section, one can single out the following in generalized form:
- priority in the organization of multi-profile intensive care hospitals without age restrictions;
- increase of radii and number of served population;
- reduction of the number of beds fund;
- reduction of the terms of hospitalization (" surgery of one day");
- new forms of hospitalization (day care, "hospital at home", provision of diagnostic and ambulatory care);
- reduction of the number of hospital centres and operational units;
- the use of external suppliers of non-clinical
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(non-medical) services ("outsourcing"), such as network laboratory diagnostic centres, laundry services, information technology, nutrition, cleaning, transportation, etc.;
- concentration of high-tech activities in large hospitals and health centres with simultaneous withdrawal from low-tech hospitals;
- transfer of more responsibilities from doctors to nurses;
- the establishment of hospital networks of hospitals (cooperatives) to ensure coordination of the provision of medical care to the population;
- hospital integration for hotels for patients;
- expansion of the network and activation of use of palliative care or hospices.
Consequently, all considered global trends should be taken into account when developing a new domestic urban network of secondary health care facilities and, above all, it is necessary to restructure hospitals in accordance with the needs of the combined territorial communities and hospital districts with the differentiation of the functions of hospitals by the degree of medical care: intensive, planned and treatment of chronic diseases, regenerative, palliative and medical and social assistance.
Turning to the consideration of the next level of medical care of the population of Ukraine, it is necessary to provide a definition of tertiary (highly specialized) medical care - medical care provided in outpatient or inpatient settings in the planned or emergency cases and involves counselling, diagnosis, treatment of diseases, injuries, poisoning, pathological conditions, conduct of physiological conditions (during pregnancy and childbirth) with the use of high-tech equipment and / or highly specialized m dychnyh high complexity procedures; the referral of the patient takes place in accordance with the medical evidence for the provision of tertiary (highly specialized) medical care in another specialization, as well as for the diagnosis and treatment of rare diseases [1]. According to the definition of WHO, tertiary (highly specialized) medical care - assistance that requires high-quality care, which, as a rule, can be provided only in specialized centres and hospitals specially equipped for this purpose. Tertiary care is provided by highly specialized multi-profile or single-state public, communal and private health care institutions, the list of which, according to the legislative provisions, is determined by the Cabinet of Ministers of Ukraine.
Tertiary medical care is provided in accordance with the medical certificate provided by the provider of primary or secondary medical care or a health care institution that provides primary, secondary or tertiary care, including other specialties; patients with chronic diseases who are on the dispensary record in a relevant highly specialized multidisciplinary or one-way health care institution; for patients in urgent condition [2]. The clinical base of the institution of tertiary care provides for its use for the development and implementation of priority scientific research, pre-and post-graduate training of healthcare workers. In this sense, the architectural task of reconstruction, modernization or new design is to provide tertiary hospitals with educational and
research corps with all the components of these processes.
Tertiary care services should include narrow-profile hospitals (hospital and republican significance), including children's hospitals, narrow medical clinics and medical diagnostic centres that provide treatment for complicated, rare or expensive cases. In order to improve the efficiency and compliance with modern medical standards, these institutions must be distinguished by considerably better material and technical support, complexity of structure and functions, as well as the radius and number of services provided by the population. A separate structural subdivision of tertiary medical care facilities should be an advisory and diagnostic medical centre with the possibility of outpatient treatment and in day-care facilities as well as emergency medical services. Compulsory are the specialized departments of the hospital, auxiliary medical and prophylactic units (clinical, biochemical and bacteriological laboratories, functional diagnostic departments, path anatomical, physiotherapeutic and radiological departments). In case of the patient's inability to reach the hospital tertiary medical level (acute phase of health or emergency hospitalization), the optimal means of special movement (air or ground special transport) should be used for transportation, depending on the patient's condition, distance, meteorological conditions, season, time day The use of special medical transport should also be foreseen in case of planned or emergency transportation of donor blood and its preparations, canned organs and tissues, and medications. The indicated features (helicopter site(s) with appropriate means of vertical communications, convenient transport accesses from different sides of the hospital complex, garages for special transport, etc.) should be taken into account in the architectural and urban design of tertiary health care hospitals.
Specialist clinics should be included in the specialized facilities of the TMD. The dispensary is an institution that provides outpatient and inpatient care for certain diseases (tuberculosis, sexually transmitted diseases, mental illness, etc.). Dispensaries consist of a consulting and diagnostic centre and a hospital. When organizing the work of these institutions, the characteristics of each dispensary, which are determined by the etiology, clinic, epidemiology of specific diseases, are taken into account. Today, in Ukraine, according to the approved list of health facilities, there are 11 types of profile dispensaries. The reduction or increase of these types, the decision on their organization, restructuring, conversion, closure should be taken within and within the conditions of individual hospital districts, depending on the needs of the population, demographic and density indicators of the area, the dynamics of morbidity.
The main functions of the city-planning network of institutions of tertiary level of medical care include:
- providing patients with highly qualified, highly specialized and unique medical care;
- formation of research and clinical centres of innovative development of the national science, education and production.
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When analyzing the world experience in the organization of a city-planning network of tertiary care institutions, it should be noted that the number of similar establishments in most European countries is minimal (compared to the secondary level). Often in countries with high health care there are four hospitals that provide technologically advanced tertiary care: two are located in the capital, and two others in the largest central cities of the country. Typically, TMD hospitals also carry out training and research activities (university educational hospitals). A typical example of providing tertiary highly specialized care is organ transplantation. Similar establishments providing TMD, serve population of not less than 1 million and not limited to the territorial boundaries. The priority task in the field of integration of practical health care and medical science and education is the separation of hospitals from an existing tangible fund, which should serve as tertiary level of medical care. The next step should be their appropriate development, optimization, and, if necessary, expansion, in order to comply with world standards on this issue. An important issue is the establishment of university clinics, since in Ukraine today there is no single management of medical, educational and research processes, there is no delimitation of the issue of mutual responsibility for the organization of medical and educational work. The classic university hospital is multidisciplinary (in which more than 20 areas are developed, each of which trains specialists and research, provides highly specialized medical care to the population) and is designed for 1,5-2 thousand beds. The form of association for the creation of such hospitals in Ukraine may be a state corporation, which, on a contractual basis, combines selected hospitals and higher educational institutions of level IV of accreditation, delegating to each other separate powers of centralized regulation of activities.
Creation of university hospitals on the basis of multidisciplinary medical institutions and higher medical education institutions of the IV accreditation level and institutions of postgraduate education will allow: to mobilize the scientific, intellectual, economic, technological, organizational and managerial potential and personnel resources of regional hospitals and higher educational institutions; to provide provision of highly specialized (tertiary) medical care, to improve the quality of training of medical personnel and the effectiveness of scientific research, their implementation into practice; to attract investments in health care. Therefore, it is on the tertiary level of medical care, based on world trends and the actual state of health of Ukraine today, it is advisable to allocate highly specialized hospitals intended for the maintenance of a purely children's category of the population of our state. The above-mentioned approach will allow to form conditions for the concentration of the best architectural support, medical personnel, equipment, etc. aspects of the formation of a full-fledged medical environment.
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