The principle of operation of PHC

MINISTRY OF PUBLIC HEALTH AND SOCIAL DEVELOPMENT OF REPUBLIC OF KAZAKHSTAN

KARAGANDA STATE MEDICAL UNIVERSITY

S.M.KABIEVA

INTRODUCTION TO THE CLINIC

TEXTBOOK

Karaganda 2014

УДК 616.08 (02)

ББК 53.5я7

К12

Reviewers:

Молотов-Лучанский В.Б. – pro-rector of study and educational work of Karaganda State Medical University, Doctor of Medicine, professor

Алиханова К.А. – Head of general medical practice department, Faculty of persistent development of Karaganda Medical University, Doctor of Medicine, professor

Смагулова Г.А. – Head of department of propedeutics of internal diseases and clinical pharmacology of Marat Ospanov West Kazakhstan State Medical University, Doctor of Medicine, docent

К12 Kabieva S.M. Introduction to the clinic: Textbook, volume I. – Karaganda – 2014 – 280 p.

ISBN

Textbook was prepared in accordance with the JI 2006 on specialty «General Medicine» and contains informative material on the topics provided by a model program on this discipline. In this book were particularized the aspects of sanitary and anti-epidemic regime in health care settings, indicators of the functional state of the patients. Particular attention is paid to the care and monitoring of patients, the optimal sequence of actions represented in the performance of therapeutic and diagnostic procedures. Theoretical material is supplemented by illustrations to better mastering the material. Textbook is aimed for 1-2 course students of medical universities on specialty “General medicine”.

УДК 616.08 (02)

ББК 53.5я7

Discussed and approved on meeting of Educational Methodological Board of KSMU

Protocol № from.... 2014.

Confirmed and recommended for edition by Academic Council of KSMU

Protocol № from.... 2014. Confirmed and allowed to press by educational methodical section of Ministry of education and science

Protocol № from.... 2014.

© Кабиева С.М.

© ЖШС «Эверо», 2014

CONTENTS

List of shortenings ………………………………………………….7

Introduction ………………………………………………………….8

CHAPTER I. SYSTEM OF ADMINISTERING MEDICAL AID

TO THE PEOPLE IN KAZAKHSTAN ………...............................10

1. Maintenance and kinds of medical work………………..............10

1.1 Kinds of medical aid………..…………………………………...10

1.2 Forms of administering medical aid……………………….........11

2. Main types of health facilities………………………………..…...13

2.1 Ambulatory types of health facilities……………………….…….14

2.2 Hospital institutions……………… …..........................................18

3. Organization of work on primary health care phase ……………...20

3.1 Principle of primary health care system’s work…………..……….20

3.2 Administrative duties of a doctor…………………...………........22

3.3 Administrative duties of sister…… ………………........................24

4. Organization of work in hospital…. ………… ………………...25

4.1 Principle of reception’s work……………….………………………26

4.2 Principle of therapy department’s work………………..............29

4.3 Administrative duties of attending medical doctor …......................32

4.3 Administrative duties of head nurse………………………….......33

4.4 Administrative duties of nurse……………………...……...........34

4.5 Administrative duties of an assistant nurse………………………..36

4.6 An order of administering in-patient care… …………….........37

CHAPTER II. NURSING PROCESS……… ………………………..42

1. Character of nursing process phases……………... ……………….42

1.1 First phase of nursing process………...........……………..............42

1.2 Second phase of nursing process……. ………………...................43

1.3 Third phase of nursing process……… ……………………….......47

1.4 Fourth phase of nursing process………… ………….....................48

1.5 Fifth phase of nursing process……… …………………................49

CHAPTER III. SAFE HOSPITAL ENVIRONMENT …....…..........50

1. Infectious safety……………...…..………………………….........51

1.1 Pathogens and ways of transmission of healthcare-associated infections………………………………………………..……………..……......51

1.2 Sources of healthcare-associated infections and risk group…….....52

1.3 Factors influence an origin of healthcare-associated infections……53

1.4 Diseases related to healthcare-associated infections………..……...54

1.5 Causes of origin and development of healthcare-associated infections......54

1.6 Prevention of healthcare-associated infections………………........55

2. Sanitary and anti-epidemic regime in health facilities..……….........56

2.1 Kinds of housekeeping in health facilities……………………….57

2.2. Hygiene of staff…………………………………………………….59

2.3 Decontamination (cleaning) of hands………………………..........60

3. Disinfection.. ……………………………………………………...67

3.1 Kinds of disinfection …………………………………….................67

3.2. Mechanical method of disinfection ……………………………..68

3.3 Physical method of disinfection ………………...........................68

3.4 Chemical method of disinfection ………………………………..71

3.5 Classification of anti-infective agents……… ……………….......71

3.6 Anti-infective agents allowed for using in Republic of Kazakhstan……………………………………………………………………....74

3.7 Technique of anti-infective solution preparation…………………78

3.8 Precautionary measures during work with anti-infective agents……..………………………………………………………………79

3.9 First aid at accidental poisonings by disinfecting drugs……………………………………………………………...............80

3.10 Biological method of disinfection…… …………………………….82

4. Sterilization….. ……………………………………………………..82

4.1 Phases of decontamination of medical aimed products……………..84

4.2 Kinds and methods of sterilization………………............................89

4.3 Steam method of sterilization… ………………................................90

4.4 Aerial method of sterilization…….. ……………………..................92

4.5 Chemical method of sterilization…… …………………...................93

4.6 Gas method of sterilization…… ……………………………............94

4.7 Methods of control at quality of sterilization…… ……....................95

5. Medical waste………… …………………………………………….96

5.1 Classification of medical waste…………. ………………………….99

5.2 Code of good practice with medical waste…..…………………...101

6. Safe environment for patients and staff………..…………………..104

6.1 Health-protective regime……….. ………..………………………104

6.2 Regimes of motor performance in hospital………… ……………..105

6.2 Concept of biomechanics ……….…………………......................107

6.4 Kinds and methods of patient transportation…. …………………..110

6.5 Transportation by stretcher ……….……………………………….113

6.6 Transportation by wheelchair……….. ……………………….......122

6.7 Other methods of transportation………… ……………………….125

6.8 Assistance at independent transportation of patient………. ……..133

CHAPTER IV. EVALUATION OF FUNCTIONAL STATUS OF

PATIENT ………………………………………………………….........138

1. Character of main need of human……………………. …………..138

2. General status of patient….. ……………………………………..144

3. Status of consciousness ………………………………………….145

4. Kinds of patient’s position in bed …………..……………………147

5. Methods of anthropomorphic measurement ……………………..150

6. Thermometry ……………………………………………….........154

7. Evaluation of status of skin cover…… …………………………..164

8. Evaluation of status of breathing..……………………………….167

9. Pulse and its properties ……………………………………………170

10. Investigation of arterial pressure………. …………………..........174

11. Identification of fluid balance.. …………………………….........181

CHAPTER V.. PERSONAL HYGIENE OF PATIENT.………………..183

1. Cleansing the patient at admission department……………..…...183

1.1. Carrying out a bath or a shower………………. ………………....183

1.2. Haircut……….. …………………………………………………..185

1.3. Shaving ………………………………………………………........185

1.4. Organization of anti-pediculosis arrangements……. …………...186

2. Principles of care of seriously ill patient………………………...190

2.1 Changing bed-linen for seriously ill patient..……………………192

2.2 Changing underwear for seriously ill patients…………………..195

2.3 Different kinds of laying patient in bed…………….……………196

2.4 Nurse’s interventions at satisfaction of compromised need………………………..…………………………………………….198

2.5 Skin care…….. …………………………………………………...202

2.6 Care and prevention of bed sores…..…………………………......203

2.7 Washing feet in bed… ……………………………………………214

2.8 Nail care……………………………………………………………216

2.9 Mouth cavity care…... ……………………………………...........217

2.10 Hair care…………. ……………………………………………..222

2.11 Eye care………. …………………………………………………224

2.12 Nose care……. …………………………………………………...226

2.13 Ear care………. …………………………………………………..228

2.14 Assistance at bowel and bladder habits………. ………………...230

CHAPTER VI. NUTRITION OF PATIENTS ……………...............239

1. Main food ingredients…………… ………………………...........239

2. Regime of nutrition………………………………………………..247

3. Clinical nutrition… ……………………………………………….248

4. Organization of patients’ nutrition in department…………..........262

4.1 Peroral nutrition……… …………………………………………...262

4.2 Artificial feeding ………..………………………………………...264

LITERATURE ……………………………………………………….271

LIST OF SHORTENINGS

АP - arterial pressure

HIV - Human immunodeficiency virus

WHO - World Health Organization

HEI - Higher Educational Institution

GDFMA – guaranteed dimension of free medical aid

MAP - medical aimed products

SUB - safe utilization boxes

HF - Health facility

MHRK - Ministry of Health of Republic of Kazakhstan

MSP - medical and sanitary part

PHC - primary health care

DMAP - daily monitoring of arterial pressure

SR - sanitary regulations

AIDS - acquired immunodeficiency syndrome

SEI - sanitary-and-epidemiologic institution

LLC - limited liability company

CNS -central nervos system

INTRODUCTION

Public health service is a public domain which ensures the availability of medical care of good quality. National Healthcare Development Program of the Republic of Kazakhstan "Salamatty Kazakhstan" defines the priority strategic objectives in the development of health care directed at improving the health of citizens of Kazakhstan. One of the priority directions of reforming the modern health care system in the Republic of Kazakhstan is improving the public health through the development and perfecting of primary health care based on the family principle.

Thereupon, a major figure on the level of primary health care to the population is a general practice doctor (family doctor). General practitioner is a generalist, the doctor-universalist, well oriented in the major medical specialties and is able to provide multidisciplinary care for common diseases and emergency conditions in the prehospital phase. Establishment of a family doctor service is aimed at early detection of disease, the formation of a healthy lifestyle, to preserve the country's labor potential and reducing premature mortality.

The successful implementation of reforms in health care requires changes in the system of professional medical education. Along with the studying of fundamental disciplines during the 1^st and the 2^nd courses a student should learn the basics of medical knowledge which are necessary in the professional work of the future physician. Thereupon, working plans of all medical universities of Kazakhstan were introduced a new discipline of "Introduction to the clinic."

This is the first clinical discipline for students of the Medical University. First steps in clinic have an influence on many things. First of all, they need to realize the correct choice of profession, the immutability of compliance with rules and standards of professional ethics. Any student entering the clinic must remember that it is viewed as the representative of the medical profession, it is judged by a new generation of future physicians.

Discipline is related to the basic (general professional) disciplines and is designed for students of 1-2 year of bachelor degree of "General Medicine" specialty. "Introduction to the clinic-1" discipline introduces students to the fundamentals of the organization of health care facilities, to providing sanitary-epidemiological regime there, to knowledge and techniques necessary to monitor and care for the sick. In the study course of "Introduction to the clinic-2" students learn the basic principles of clinical work with patients who require monitoring and care, mastering the handling technology, skills of first aid to the patients, expertise and techniques necessary to monitor and care for the sick.

Nursing care cannot be considered as minor or as "stepchild of medicine." This is a condition without which it is truly impossible to effectively fight against disease. Nursing covers many aspects of patient care. This is the classic techniques of monitoring the functional state of the patient (performance status, anthropometric studies, assessment of respiratory, circulatory, etc.), and well-known medical procedures (injections, gastric lavage, setting enemas, thermometers, etc.). An important thing in future doctor’s activity is the ability to conduct syndromic disease diagnosis and to assess the patient's condition over time.

Learning the basics of resuscitation is also an important component of medical education at any level. With the help of these tutorial students will learn important concepts of terminal conditions, clinical and biological death and ways of urgent help to these categories of patients.

In future professional activity doctor is responsible not only for his prescriptions but also as a leader in the medical team he must be able to organize the work of middle and junior staff. The specific of general practice doctor’s work requires extended and optimal professional training to provide comprehensive medical care.

CHAPTER I

SYSTEM OF ADMINISTERING MEDICAL

AID TO THE PEOPLE IN KAZAKHSTAN

Maintenance and kinds of medical activity

Healthcare is a collection of political, social, economic, scientific, legal, medical, sanitary and hygienic, anti-epidemic and cultural measures aimed at preserving and strengthening the physical and mental health of the citizen.

Medical activity includes professional activity of individuals who have higher or secondary professional medical education, as well as legal persons carrying out activities in the field of health care.

1.1 Kinds of medical aid:

Pre-doctor care;

Qualified medical aid;

Specialized medical aid;

Tertiary health care;

Health and social care.

Pre-doctor care is administered by health professional who has secondary medical education. In an emergency pre-doctor care may be provided by persons without medical education: self-help, citizens' mutual help, help of sanitary officer, help of specially trained representatives of a number of "social" professions (so-called paramedics) – policeman, fireman and other.

Qualified medical care is provided by health professionals with higher medical education in diseases which do not require special methods of diagnosis, treatment and medical rehabilitation.

Specialized medical care ismedical assistance provided by specialized experts in diseases that require special methods of diagnosis, treatment and medical rehabilitation in the form of consultation of "highly specialized doctors" (cardiologist, neurologist and others.) or in specialized departments of general hospitals.

Tertiary health care ismedical care provided by experts specialized in diseases that require the use of new technologies of diagnosis, treatment and rehabilitation (for example, endovideosurgery, transplantation).

Health and social care is medical care provided by dedicated professionals to the people with socially significant diseases and diseases that are a danger to others. According to the decision of the Government of the Republic of Kazakhstan dated December 4, 2009 to the number of socially significant diseases are included: tuberculosis, HIV (AIDS), hepatitis B, C, cancer, diabetes, mental disorders, cerebral palsy, myocardial infarction (first six months), rheumatism and others.

Forms of care delivery

Medical care is administered in following forms:

1) outpatient care which includes primary medical care, consultative and diagnostic care

2) hospital care;

3) hospital-replacing care;
4) emergency medical service;

5) air medical service;

6) medical care in an emergency;

7) restorative care and medical rehabilitation;

8) palliative care and nursing care;

9) traditional medicine, folk medicine (healing).

Primary medical care (PMC) is pre-medical or qualified medical assistance without round-the-clock medical supervision, which includes a set of available medical services provided at the level of individual, family and society:

1) diagnosis and treatment of the most common diseases, injuries, poisonings and other emergency;

2) sanitary and hygienic, anti-epidemic arrangements and prevention of diseases;

3) educative activities.

PMC is provided by following specialists: primary care physicians, paediatrists, obstetrician-gynecologists, general practice doctors, medical assistants and nurses. The activities of organizations that provide primary health care based on the territorial principle in order to ensure access to health care to citizens at their place of residence and (or) the attachment with the right of free choice of medical organization.

Consultative and diagnostic care is specialized or tertiary medical care without round-the-clock supervision.

Hospital care is form of administering of qualified, specialized and tertiary medical care with round-the-clock supervision. Healthcare organizations which administer hospital care provide proper care and nutrition.

Hospital-replacing care is form of administering pre-doctor, qualified, specialized and tertiary medical care with medical supervision lasting from 4 to 8 hours per day.

Emergency medical service is form of administering medical care in the event of diseases and conditions that require emergency medical care to prevent significant harm or to eliminate threat to life. Emergency medical assistance is free of charge from the state budget for citizens of the Republic of Kazakhstan, foreigners and stateless persons. Organizations of ambulance are prohibited from engaging in paid services.

Air medical service is form of emergency medical care at impossibility of administering medical care due to lack of equipment or trained staff in the medical organization at the location of the patient. Providing medical care is carried out by delivery of qualified specialists to your place of destination or transport the patient to the appropriate medical organization by various kinds of transport.

Restorative care and medical rehabilitation are administered to the citizens suffering from inborn and acquired diseases and also from consequences of acute and chronic diseases and injuries in departments of rehabilitation and sanatorium-and-spa organizations.

Palliative care and nursing care are administered underthe guidance of a doctor for incurably-ill patients in the terminal (final) stage of the disease in the specialized departments of the hospital, hospice or in the form of hospital at home. Nursing care is carried out in cases which do not require medical supervision.

Traditional medicine, folk medicine (healing).

The methods of traditional medicine are homeopathy, hirudotherapy, manual therapy, reflexology, herbal medicine and treatment by means of natural origin. The right to do healing has a person with medical education in the presence of proper license.

Conducting mass healing sessions including the use of mass media, is prohibited. Persons who illegally work in traditional medicine (healing) will be liable in accordance with the laws.

Main types of health facilities

In Kazakhstan, 80% of medical institutions are state-owned, 20% of them are private, therefore, the state plays a major role in medicine. With a population of over 17 million people, the capacity of the medical market of Kazakhstan is estimated by experts in the amount of more than $ 500 million. In the whole country 54,800 doctors and 117,000 nurses provide health services.

Institutions providing medical care are called health facilities (HF). Health facilities should be located in accordance with the master plan of settlement and town plan.

It is not permitted to appropriate admeasure for construction in areas previously used for rubbish dump, clearing field, cattlegrave, cemeteries, the soil of which has pollution of organic, chemical and radiological nature. Health care facilities should be placed no closer than 30 m from the red line of the building and not less than 50 m from residential and public buildings and away from railways, airports, highways and other powerful sources of influence of physical factors taking into account ensuring an acceptable level of noise. The public health care facilities should be comfortable by small architectural forms for the rest of the patients.

It is not allowed to pass through the territory of health care facilities for transit high-voltage transmission lines with voltages above 110 kV, as well as the trunk engineering services of urban / rural purposes (water supply, sewerage, heat supply and others). The area of green plantations and lawns should be not more than 40% of hospital area and clinics with the hospitals.

There are two main types of health care facilities: outpatient and inpatient. More than 80% of patients get outpatient medical care and about 20% get inpatient care.

Outpatient types of health care facilities

This medical institution, which provides medical assistance to incoming patients and patients who are at home. Institutions of outpatient type include: polyclinics, ambulatories, dispensaries, medical-sanitary units and ambulance stations.

Polyclinic is multifield health care facility working on territorial-local principle. The territory assigned to the clinic, divided into sections with a certain number of adult and child population. Each parcel served by fixed doctors and nurses. Treatment-and-prophylactic work is organized by local doctor, he directs nurses and attracts specialists of different profile. The polyclinic provides medical care to the population, including special, and, if necessary, observation and treatment at home.

The polyclinic is provided with the necessary equipment for examination and treatment of patients. All outpatient institutions have three groups of premises: for registration and expectations of the appointment, medical and diagnostic premises, service and household purposed rooms. Doctors of different profiles provide an appointment in polyclinics (therapeutics, surgeons, ophthalmologists, otorhinolaryngologists, endocrinologists, cardiologists and others). The clinic has basic diagnostic rooms: x-ray, ultrasound, functional diagnostics, clinical and biochemical laboratories, as well as classrooms and offices for conducting medical procedures and doctor's prescriptions (procedural or dressings, physiotherapy department, physiotherapy room and others).

The registry is placed near the entrance. It also provides a pointer of rooms and specialists’ schedule of appointment of patients. Hallway of the clinic, waiting rooms have tables with literature (brochures), introducing patients with disease prevention. From the waiting room the patient goes in the office of the physician or dressing room, procedure unit and other medical rooms. In the doctor's office should be all that is necessary for work: desk for the doctor and nurses, chairs, couch, hot and cold water, towel, smock, tonometer, phonendoscope, prescription forms and other).

Ambulatory is health care facility which serves to assist the population of a small urban village, industrial enterprise or rural area on the district and territorial characteristic. There are only doctors of the main specialties in ambulatory: therapeutic, surgeon, dentist. Staff of ambulatory besides doctor has medical assistants, midwives, nurses and hospital cleaners. Ambulatory has the following rooms of pre-doctor admission, electrocardiographic examinations and procedure unit. The principle of work is the same as the polyclinic’s.

Obstetric and medical assistant’s point is health care facility providing pre-doctor medical care in rural areas. It is organized if the town is situated at a great distance from other hospitals (more than 4-6 km). Works at district principle. There is a pharmacy for official medicines sale.

The staff includes a medical assistant, a midwife and hospital cleaner. The staff of medical assistant and obstetric point provides medical care to outpatient care and home care, emergency and first aid, identifies infectious patients, carries out anti-epidemic measures, health surveillance at settlement, public catering and the food trade. The medical assistant performs routine medical examinations, medical examinations of the population and preventive measures. The midwife provides care for women during pregnancy and childbirth, performs nursing of puerperant and children up to 3 years.

Medico sanitary department (MSD) is health care facility of outpatient type, organized at industrial plants to care for workers and their families, serves workers of attached company on the principle of system shop floor physicians. In MSD, as in polyclinics, work doctors of major specialties and specialists in professional pathology.

MSD is a comprehensive health care facility, which, besides polyclinics, may include hospitals and health centers, dispensaries, sanatoriums, children's health camps and other.

Objective of MSD is first aid, prevention of diseases associated with the process, and treatment of patients. Precinct (shop) doctors and nurses study the working conditions of workers and employees at the workplace, identify occupational hazards and participate in the development of a set of preventive measures aimed at improving working conditions and life of the employees, prevention of industrial injuries.

Health center is usually part of polyclinic or medicosanitary department of company and is not an independent health facilities. The health centres are organized in larger shops, close to work or construction site. There are medical and medical assistant health centers.

The main function of the medical staff of the health center (doctor, medical assistant, nurse) is administering pre-doctor and first aid for employees in case of injuries, poisoning, emergency conditions and carrying out procedures prescribed by a doctor of polyclinic or MSD (injections, bandaging), vaccination, clinical examination and health education.

Dispensary is special specialized facility of outpatient type, carrying out all the work of the dispensary method (maintenance of patients with certain types of diseases). There are psychoneurologic, narcologic, dermatoveneral, anti-tuberculosis, oncological, cardioreumatologic and endocrinology dispensaries.

The main function of dispensaries is treatment and prevention of diseases of any one kind. For example, a tuberculosis dispensary engaged in the treatment of TB patients, TB prevention among persons surrounding the patient at home and at work, mass screening of the population for early detection of TB, prevention of disease by vaccination, etc. Thereafter oncology dispensary engaged in treatment and prevention of malignant tumors, etc.

Ambulance station is health care facility is designed for round the clock emergency medical care to patients in the prehospital stage at all life threatening conditions (trauma, injury, poisoning, bleeding, stroke and other diseases) and also in childbirth.

Specialized medical care is carried out by team headed by a physician, physician's assistant (nurse), which assists the physician in providing medical care at home and transportation of patients.

The ambulance stations must be provided by direct operative communication with ambulance substations, hospitals, fire service of medical-sanitary unit, police, gas emergency. Managers-tow trucks should be provided with radio communication with the sanitary vehicles on line.

Inpatient health care facilities

These are hospitals, clinics, maternity homes, sanatoriums, hospices, day hospital.

Hospitals are designed for in-patient treatment. Inpatient care (lat.stationarius –

standing, motionless) is form of providing skilled, specialized and highly specialized care with round-the-clock supervision.

Hospital is health care facility, where are patients requiring continuous around the clock medical supervision and care. Here is carrying out emergency, planned treatment of patients who are need in constant supervision or in application of methods of treatment which are impossible or difficult in the outpatient setting (operations, frequent intravenous, intramuscular injections and other procedures).

Hospitals are divided into:

• one-field healthcare facilities specializing in the treatment of patients with certain diseases (tuberculosis, psychoneurological, infectious and others);

• multifield hospital with multiple departments for treatment and diagnosis of various diseases (therapy, surgery, neurology, otorhinolaryngology and other departments).

Coverage serviced areas:

• the district;

• city;

• regional;

• republican.

Clinic is the hospital where is not only inpatient care of patients, but also teaching students and research work. Clinics offer a highly professional medical staff and modern equipment for diagnostics and treatment of patients.

Hospital is specialized health care facility providing treatment and diagnostic services to current and former military personnel, veterans and disabled war veterans, and persons affected by military action.

Kinds of hospitals:

• сentral;

• types of armed forces;

• the district;

• the garrison.

Hospitals formed in military times:

• movable and field;

• evacuation;

• the rear.

Sanatorium (lat. sanare – to cure, heal) and dispensaries is health care facility of hospital-replacing type, assisting patients during aftercare with the use of factors of nature: air, sea water, mineral waters, therapeutic muds and other, organizes health monitoring duration from 4 to 8 hours during the day.

Dispensaries are organized at large enterprises in a forested area not far from the village, sanatoriums are in resort areas.

Maternity homes are health care facility providing medical assistance to pregnant women, women in childbirth and puerpera. Large maternity homes also assist gynecological patients.

Maternity homes are closely linked with health care facilities of the district (with clinics, anti-TB and dermatovenerologic dispensaries) which creates conditions for a comprehensive and complete medical care. Maternity hospital includes antenatal clinic and providing social and legal assistance to pregnant women.

Hospice (English hospice) is medical facility in which patients with predicted poor outcome of the disease receive good care and maintenance. The hospice patients are surrounded by the usual "home" things, they have ready access to family and friends. The medical staff provides palliative care: patients can receive the oxygen, analgesics, the probe nutrition, etc. Minimum of doctors and maximum of paramedical personnel.

The main purpose of hospice stay is to brighten the last days of life, to alleviate suffering.

Day care is designed for few hours stay for patients, when patients are consecutively performed several medical procedures or diagnostic tests. As a rule these procedures are organized at polyclinics.

Day care, as a rule, includes:

- the room with nurse’s area;

- doctors ' offices;

- procedure unit;

- premises for day-stay of patients;

- sanitary and hygienic rooms;

- storage for clean and dirty linen.

Trauma center at the hospital provides emergency round the clock assistance to the population in case of injuries.

Organization of work in health facilities

The principle of operation of PHC

Primary health care as the most affordable, economically and socially most acceptable form of medical care, is the core of the entire health system, as 80% of patients start and end their treatment within primary care. The first level of contact of individuals, families, society with the national health system allows you to bring medical care near to the place of residence. A strong system of primary care produces better health outcomes at lower costs and higher public satisfaction with medical care.

Primary health care includes all types of outpatient care, emergency and urgent care, obstetrics, sanitary and anti-epidemic agencies and represents a totality of health improving, security, preventive, diagnostic, therapeutic and rehabilitation measures.

In the framework of health sector reforming in the Republic of Kazakhstan each site has 1 general practice doctor, 2 nurses, 1 midwife, who are responsible for conducting all medical and preventive measures for the fixed site.

The mode of work of outpatient care in the framework of guaranteed amplitude of free medical aid is installed from 08.00 to 20.00 hours on a rolling basis for all professionals and departments with ensuring work of doctors on duty on weekends and holidays. Duration of working hours of primary care physician (General practitioner, doctor therapist/pediatrician) at the reception is not less than 5 hours a day. The call service at home by a doctor or healthcare worker is coordinated by the head of precinct general doctor service but in his absence, by the local doctor (general practice doctor). Call acceptance ends 2 hours before the end of the work of the organization of primary health care (up to 18.00 o’clock).

Indications for the call service at home are:

1) acute painful conditions that do not allow the patient to independently visit the PHC organization:

· fever above 38 degrees C;

· increased blood pressure with evident disorder of health state;

· multiple liquid stool;

· severe pain in the spine and joints of the lower limbs with reduced mobility;

· dizziness, severe nausea,vomiting

2) chronic painful conditions that do not allow the patient to visit the clinic (severe cancer, disabilities (I - II group), paralysis, paresis of extremities);

3) acute infectious diseases that pose a danger to others;

4) nontransportable patient;

5) call service passed from the ambulance station, in hours of organization of primary health care.

Active visiting the patient at home by medical worker of PHC organization, including through door-to-door (apartment) ward rounds is carried out by:

1) acute illness, exacerbation of chronic diseases with the purpose of monitoring its condition, disease and timely assignment (correction) necessary examinations and / or treatment;

2) the patronage of certain population groups (pregnant women, newborns) or at identifying patients with infectious disease, persons which had a contact with these people and persons suspected for infectious disease

The specificity of professional activity of a family doctor is determined by several parameters:

· by integration of administered medical care, professional activity of a family doctor accumulates several types of care (diagnostic, therapeutic, rehabilitative, preventive, health education, medico-social, advisory and organizational),

· by focus on the family as the unit of health (family doctor decides all questions of medical impact on the family),

· by priority of prevention direction in professional activity,

· by administering medical care to multi-age group of patient on an ongoing basis,

· by multifaceted nature of the relationship along the line of "doctor-patient", the public importance of the profession,

· by high effectiveness of family doctor’s activity in social, economic and organizational sense.

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