Análisis del incremento de la iniciativa propia en las urgencias del hospital de Riotinto

Laburpena

Introduction. Between 2003 and 2008, the self-referred patients admitted the Emergency Department of Hospital of Riotinto in Huelva – Spain (SUHRT) was multiplied by 2,97. That fact transformed its rural hospital character. Goals. To identify the reasons that increased the number of these self-referred patients (IP), to know the opinion of the health personnel as well as the users of sanitary facilities and to compare between the different health areas in the Huelva Province Methods. We studied the 242508 patients who were treated in the Emergency Room of our hospital between 2003- 2011 and 2015, separated in two periods, 2003-07 and 2008-2015. We observed the inflection point in 2008 excluding the period between 2012 and 2015, when we had registration mistakes. We collected data’s from Out-of-hospital emergency medical services (DCCU) of other Health Districts of the province and the Emergency Department of the Juan Ramón Jiménez (HJRJ) and Infanta Elena Hospitals (HIE). Social and demographic elements, origin, temporality, health services and their location, health care level and organization changes were analysed. Descriptive statistics, chi-square test, binary logistic regression analysis (IBM © SPSS Statistics 20.0 ©) and analysis of standardized mortality by the indirect method (Epidat4.1 ©) were performed. we finished by qualitative analysis of 4 discussion groups. Two of them were patients and the other two were physicians, (Atlas.ti 6.2 ©). Results. we studied a rural and remote region, with a large dispersion, low population density (18.6 habitant/Km2), regressive social and demographic indicators and aging. It has underdevelopment level, inequality and high mortality rates (1251.6 ± 51.6 deaths / 100000 habitant). The Standardized Mortality Rate is 108.1 (CI 95% 101-115.6)). Dispersion causes insufficient human resources, with asymmetrical patients quota, low medical / clinic ratio, and absence of EPES-061 teams. Most of patients attended by SUHRT since 2008 were women, self-referred patients, with low severity diseases, so they were not admitted in the hospital. They use to come from Riotinto basic health area, at mornings time, suffering mixed medical and surgical processes. The logistic regression model shows that the changes produced in the health system in 2008 and the time that takes to reach the DCCU affect the probability to be attended cause of IP or being sent by the GP to the SUHRT. Since 2008 the probability of IP is 76,43% in the towns that the people need 6 minutes or more time to reach the DCCU. When we included the triage levels at 2015, we observed changes in the time that the patient takes to go to the DCCU and both factors simultaneously affect the patient's origin. The logistic regression model was correctly classified in 83.1% of IP. The qualitative study allowed us to know that the changes suffered in the health system (OPE, transfers of healthcare staff, contracting decreases, closure of DCCU of Minas de Riotinto). It decreased the patients accessibility to the health facilities and the patient lost his reference physician. That worsened the patientphysician relationship which led to the mistrust in primary care assistance. The DCCU frequencies follow a different pattern than the hospital one and it is very high (5 th of Andalusia), as other underdeveloped and inequality areas. Similar changes happened in the IP in the HIE area and in the West Andévalo basic health area (HJRJ). Where the patients come from in the case of HUS of the three Hospitals is influenced by the distance time factor, determined by its location in a metropolitan area Conclusions. Changes in the healthcare system and the time to reach the DCCU increase the probability of self- referred patients to the SUHRT. The opinion of the health staff and users of health facilities allowed us to know that it is the loss of trust in the referring doctor and the decrease of emergency resources outside of hospital has led to hospitalcentrism.