Romania needs Pediatric Critical Care Regionalization

1. Romania needs Pediatric Critical Care Regionalization “Salvati-va Ingerii” Foundation Catalin Cirstoveanu, MD Bucharest, March 2011

2. Health Minister Information • SUA, Canada, Austria si Israel ar putea investi in spitalele romanesti • Ministerul Sanatatii a primit cereri oficiale pentru constructia de spitale regionale de urgenta in regim de parteneriat public-privat din partea investitorilor interesati din Statele Unite, Canada, Austria si Israel. • Ministrul Sanatatii a adaugat ca prin acest proiect se urmareste crearea unor unitati compacte autonome, de urgenta, cu functionalitate integrala - investigatii, diagnostic si tratament - care sa faca posibila eficientizarea serviciului medical prin reducerea timpului necesar si a costurilor pentru stabilirea diagnosticului. • Costurile estimate de echipa de specialisti a Ministerului Sanatatii pentru realizarea acestui proiect sunt de 1,5 miliarde de euro. Ministerul Sanatatii va participa in parteneriatul acesta cu terenurile pe care se vor construi spitalele, iar companiile eligibile cu partea de finantare. • http://www.9am.ro/stiri-revista-presei/Social/209061/SUA-Canada-Austria-si-Israel-ar-putea-investi-in-spitalele-romanesti.html

3. International Health Politics Texas Children’s Hospital, USA- almost half century ago

4. International Health Politics Melbourne Children’s Hospital Hospital, New Zealand

5. International Health Politics St Thomas Children’s Hospital London, UK

6. International Health Politics Evelina Children’s Hospital at Saint Thomas Hospital, UK

7. International Health Politics Armand Trousseau Children’s Hospital Paris, France

8. International Health Politics Yangon Children’s Hospital, China

9. International Health Politics Shanghai Children’s Hospital, China

10. International Health Politics Denver Children’s Hospital , US

11. International Health Politics Schneider Children’s Hospital Tel Aviv, Israel

12. International Health Politics Birmingham Children’s Hospital, UK

13. International Health Politics Los Angeles Children's Hospital, US

14. International Health Politics Philadelphia Children’s Hospital, US

15. International Health Politics Boston Children’s Hospital , US

16. International Health Politics Loma Linda Children’s University Hospital

17. International Health Politics University, Dedicated, Integrated , Regionalized Children's Hopitals

18. International Health Politics New Children’s Hospitals!!! Modern and new buildings

20. Illness in the Community

21. National consensus Crit Care Med. 2000 Jan;28(1):236-9. Consensus report for regionalization of services for critically ill or injured children. Council of the Society of Critical Care Medicine. Abstract The care of critically ill children has become more complex and demanding. This document establishes recommendations for developing regionalized integration of the care of these children into the emergency medical services system. These recommendations were developed by pediatricians with expertise in pediatric critical care, transport, and emergency medicine from the Pediatric Section of the Society of Critical Care Medicine Task Force on Regionalization of Pediatric Critical Care and the Committee on Pediatric Emergency Medicine from the American Academy of Pediatrics. The document was developed from existing guidelines from a number of professional organizations (including the Society of Critical Care Medicine and the American Academy of Pediatrics), a thorough review of the literature, and expert consensus. PMID: 10667530 [PubMed - indexed for MEDLINE]

22. Trauma patients

23. Trauma patients – age distribution

24. Why children are not small adults? • airway and shock - paramount • head injury:  morbidity & mortality • forces over small area  multisystem injury • little or no external injury; occult injuries are common • kids die from hypoxia and resp. arrest •  heat loss, glucose & fluid requirements • psyche sequelae

25. Why children are not small adults? • severely injured do better at pediatric trauma centre • multisystem injury is RULE • use of imaging unclear: low threshold • be aware of potential abuse

26. Neonatology Oxford JournalsMedicine/ International Journal of EpidemiologyVolume31, Issue5 Pp. 1061-1068 ; 2002 Are we regionalized enough? Early-neonatal deaths in low-risk births by the size of delivery units in Hesse, Germany 1990–1999 Günther Hellera, Douglas K Richardsonb, Rainer Schnellc, Björn Misselwitzd, Wolfgang Künzele and Stephan Schmidtf Institute of Medical Sociology & Social Medicine, Medical Centre of Methodology and Health Research, University of Marburg, Germany. Department of Neonatology, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA. Faculty of Politics and Management, University of Konstanz, Germany. Institute of Quality Assurance, Hesse, Germany. Medical Centre of Gynaecology and Obstetrics, University of Giessen, Germany. Department of Obstetrics, Medical Centre of Gynaecology and Obstetrics, University of Marburg, Germany.

27. Neonatology Results: • Birthweight-specific mortality rates were lowest in large delivery units and highest in smaller delivery units. This gradient was especially pronounced within low-risk births and was also confirmed in several logistic regression models adjusting for additional risk factors. • A more than threefold mortality risk was observed in hospitals with <500 births/year compared with hospitals with >1500 births/year (odds ratio = 3.48; 95% CI: 2.64–4.58). • Further trend analyses indicated that prenatal prevention programs and the increasing usage of modern prenatal diagnostic procedures have not reduced this gradient in recent years.

28. Pediatric Surgery March 2002FromHarbor-UCLA Research and Education Institute (REI) Regionalization of hospital caseloads may decrease mortality rates in pediatric surgeries

29. Romanian Health Status Access to sanitation96% Birth rate, crude10.2 per 1,000 people Contraception64% Drug access80% HIV AIDS > Deaths350 Hospital beds > per 1,000 people6.6 per 1,000 people Infant mortality rate12 per 1,000 Life expectancy at birth > Female75.89 years Life expectancy at birth > Male68.69 years Life expectancy at birth > Total population72.18 years Maternal mortality 42 per 100,000 Physicians > per 1,000 people1.9 per 1,000 people Spending > Per person86 Suicide rate > Females 4.9 per 100,000 people Suicide rate > Gender ratio3.8 per 100,000 people Suicide rate > Males18.5 per 100,000 people Teen birth rate41 Tobacco > Cigarette consumption1,676 Tobacco > Total adult smokers43.5 Water availability9,445 cubic meters

30. Pediatric Critical Care Romania • Emergency Units - dedicated for children • Pediatric and Neonatal Transport Units– 3 units for neonates, rest of them for adults – SMURD • Critical Care Units – poor developed, non assigned doctors • Pediatric Trauma Center - no one in the country • Pediatric Neurosurgery Center - no center in Children’s hospitals • Pediatric Cardiac Centers- 30% of diseases treated • Pediatric Oncology Centers- very crowded and very high rate of mortality • Neonatal Intensive Care Units - 30- 40% of critical cases treated

31. Pediatric critical care - Romania • Pediatric Surgery – manycases abroad • Organ transplant centers - no one in Children’s Hospitals • Imaging and treatment equipment- absent or poor – IRM, radiotherapy, etc • Education - pediatric subspecialties absent

32. Tens of million of Euro are transferred outside the country for payment of medical services (in cash or through the E112 form) necessary for our children (premature newborn, children suffering from heart-related diseases or malformations, children with cancer, children who need surgery, transplants, children with politrauma etc.). • Treatment and medical procedures in Western medical units cost Romanian parents and health insurances budget huge amounts of monies, while the largest majority of children never arrive to benefit from treatment and, being inappropriately or incorrectly or insufficiently treated in Romania, die or survive with severe handicaps, a situation which triggers immense social, moral and material prejudice for Romania. • Recently established private hospitals and clinics do not represent a real alternative for the actual Romanian pediatric situation, since they only address and are able to cure only less complicated cases and only such narrow population can attend.

33. International Health Polititics Projects affiliated with Boston Children's Hospital

34. Facilities- Sau Paolo- Brasil

35. Brasil regionalization of critical care

36. Creating facilities in very poorly developed countries-Nepal

37. Results in Nepal After 3 years of preparation, the project started in June 2009. All day lectures on topics in critical care, mock case scenarios, practical equipment training and simulated procedures led to the graduation of 60 nurses. Twenty five physicians were trained for three months. The expert team worked with the locals in preparing the units, arranging furniture and equipment, stocking carts, making inventory and preparing protocols. A protocol handbook was developed on topics such as mechanical ventilation, sedation, admission/discharge criteria, procedures and management of different disease states. Various charts such as nurse observation charts, notes by residents, procedure handoffs at change of shifts were designed and printed. Infection control practices and methods of sterilizing non disposable articles were identified and protocols written. At the end of three months the units were functioning with trained local manpower and reasonable modern equipment.

38. Projects at Marie Curie Children’s Hospital • The Emergency Unit – the project, carried out in collaboration with the Foundation “Smurfit” Monaco, in value of Euro 3 million, has given the Hospital Romania’s best equipped emergency receiver unit, which receives approx. 300 children per day. • The Neonatal Intensive Care Unit and Neurosurgery – in collaboration with the Foundation “Mereu Aproape”, amounting to Euro 650,000, received a Prize for media involvement, social involvement projects promotion and resource deployment. The project comprised the relocation of a prominent neurosurgeon with experience in France and Canada. From year 2007 till present over 1000 of quality interventions have been performed. Since 2011 a second neurosurgeon works for our Hospital.

39. Projects at Maric Curie Children’s Hospital • Improvement of the Hospital’s rooming conditions – in collaboration with the Foundation “Scheherazade” over Euro 5 million were invested for the creation of civilized rooming conditions. • The Pediatric Cardiosurgery Unit – in collaboration with the Ministry of Health ,Foundation Inima Copiilor (Children’s Heart) si Ms. Liana Stanciu – which has been awarded the Prize for the best public campaign , Procter&Gamble, Sensiblu and amounted to approx. Euro 3,5 million.

40. The New MS Curie Children’s HospitalUniversity, Regional and Integrated Pediatric service

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