State Medical Service

The State Medical Service (Arvorian: Государственная медицинская служба), more commonly known as Gosmed, is the national healthcare organisation of Arvor (ADR). It is one of six major non-ministerial agencies within the government of the ADR and is one of the largest healthcare services in the world.

Overview

Founded in 7570 from the merger of the previously independent regional healthcare agencies, Gosmed's purpose is "to ensure that all citizens have access to, and receive, the compassionate, dedicated care they require to ensure a high quality of living and a life as free of illness and infirmity as possible." Its headquarters is located in the Ustinova Building in the Levoberezhny district of the capital city of Cherenovsk.

Structure

Gosmed is co-ordinated centrally from its headquarters in Cherenovsk. From there, operations are divided between four regional offices of twelve oblasts each - north, north central, south central, and south. Each of these regional offices manages operations of the Gosmed branch in each oblast under its direction. Oversight and regulation of Gosmed operations is the responsibility of the Ministry of National Health.

Each Gosmed medical centre is divided into five units, each of which addresses specific concerns and needs - general treatment, emergency treatment, surgical services, psychiatric services, and rehabilitative services. Each unit co-ordinates extensively with the others, and all have access to the to the national medical information network, a secure nationwide medical database that maintains all citizens' patient records.

Services

All citizens of the ADR have a general doctor which serves as their main point of contact with the national healthcare system. Every general doctor, or group of general doctors working together, are based out of local clinics and polyclinics found in every municipality. For all regular medical needs, general preventive care, and consultation, citizens need only arrange an appointment with their general doctor. Citizens consult with them first before seeking the services of a specialist, and if the determination is made that such is necessary, the doctor contacts the local medical centre and arranges an appointment. Wait time for appointments is typically one to four weeks.

If a citizen requires surgery, the specialist arranges a consultation with the surgical services unit, where the patient, specialist, and surgeon meet to discuss the situation before making any further arrangements. Preliminary preparation includes the necessary pre-surgery check and any necessary scans or tests, such as x-rays, MRIs, or blood draws. Wait time for surgery is typically two to five weeks.

All Arvorian citizens are issued a medical identification card (медицинское удостоверение личности) which serves as their primary means of checking in and accessing the national healthcare system. This card, the same size as a personal identification card, is light red with a white border. It displays various pertinent personal information and a picture of the individual, and a magnetic strip embedded in the card is scanned by a special reader machine whenever a citizen checks in at the clinic or medical centre, which logs their visit and allows staff to identify the person and access their file on the national medical network.

All general healthcare services are provided at no charge to citizens. These benefits include an annual physical, annual eye examination, and two dental checkups and cleanings. Additionally, senior citizens (age 65 and older) receive an annual hearing test. Required vaccinations, including the battery of vaccinations for newborn children and the regular annual vaccinations available to all citizens, such as for influenza, as well as booster doses of certain vaccinations are likewise provided at no charge.

All necessary maintenance medications are fully covered, including prescriptions for high blood pressure, heart disease, asthma and diabetes. These medications are available in thirty, sixty, and ninety-day prescriptions which can be refilled with a call to their general doctor who then calls the local chemist. Pain management medicines are strictly regulated but are covered at a minimal expense to citizens and require the patient to visit the clinic to acquire a paper prescription which then must be taken to the chemist to be filled.

Psychiatric counseling and related services are likewise fully covered and are available on a regular or as-needed basis as determined by the attending specialist. This includes coverage for up to 180 days as an inpatient at a dedicated psychiatric centre, or up to four sessions with a psychiatric counselor per month. Additional inpatient time or one-on-one sessions with a counselor are available, but the patient must bear some cost.

Some services, such as cosmetic surgery, are not covered, as it is considered an elective procedure. Reconstructive surgery, however, to correct a serious physical defect or repair injuries sustained, is covered.

Organ transplantation is extremely seriously regulated. A very specific process must be followed at all stages of certification, screening, and preparation. All such services are co-ordinated via a certified and regulated affiliate of Gosmed. Strict laws forbid any form of financial payout or otherwise in exchange for organ transplantation, and the law is not forgiving towards any who commit illegal acts in this regard.

At any Gosmed facility, as mentioned previously, services are divided between five units. Each addresses specific concerns and provides specific services. In some instances, services overlap as required. As of 7690 RH, the ADR maintains approximately 14.07 hospital beds per 1,000 population and 21.5 critical care beds per 100,000 population.

General Treatment - Provides all general and preventive care services. These units also house the specialist departments, medical imaging department, and social services department.
Emergency Treatment - Provides all accident & emergency and critical care services. This part of the medical centre also houses the infection control department.
Surgical Services - Also called a surgical centre, providing all inpatient and outpatient surgical services. Also houses the anesthetics, preoperative and postoperative departments.
Psychiatric Services - Provides psychiatric services to patients on an ongoing or as needed basis. This includes adult counseling, crisis stabilisation, extended care services, juvenile counseling, and substance abuse counseling.
Rehabilitative Services - Provides therapeutic services. This includes speech, physical, and cognitive therapy as well as drug recovery and occupational therapy.

Gosmed Constitution

Gosmed has a formal constitution which lays down the objectives of the organisation, the rights and responsibilities of the various parties (patients and staff) and the guiding principles which govern the service. All doctors, nurses, and orderlies are required to sign a form that goes in their file stating that they have read, understand, and agree to abide by the tenets of the constitution. This understanding and acknowledgment is considered as vital to their service as healthcare professionals as their affirmation of service.

Medical education

To work within Gosmed, all aspiring healthcare professionals must undergo a strict and intensive schedule of training and certification in order to become licensed. Entry-level lessons encompass all of the standard basics of healthcare, including anatomy, biology (with lab), general chemistry (with lab), organic chemistry (with lab), biochemistry, and physiology. The term of standard medical education (known as the Foundational Medical Education, Базовое медицинское образование) required depends on what tier of healthcare professional the student is aspiring to - six years for a doctor, four years for a nurse, and two years for an orderly. Each type of professional, regardless, must complete a summative assessment under the observation of a certified examiner prior to being assigned their registrar or internship period. After this, the term of internship (or residency in the case of a doctor) will take place at a medical centre near where they attended medical school. Doctors will spend three years as a doctor resident, nurses will spend two years as a nurse intern, and orderlies will likewise spend two years as an orderly intern.

Patient experience

A patient needing medical care first visits their general doctor at their local clinic, with whom they consult on their needs and determine if the services of a specialist are required. Arrangements are made for an appointment with the appropriate specialist at the local polyclinic or medical centre, with wait times for appointments typically being approximately one to four weeks. If it is determined to be necessary, the specialist can arrange an appointment for a consultation with surgical services. Preliminary preparation includes drawing blood for the pre-surgery checks and tests, and any necessary scans. Wait times for surgery are typically approximately two to five weeks. All care is paid for by the NHA.

Patients can be seen by the medical centre as out-patients or in-patients, with the latter involving an overnight stay. The speed of in-patient admission is based on medical need, with more urgent cases being processed faster though all cases will be dealt with in a timely and efficient manner. Only about one sixth of medical centre admissions are from a waiting list. For those not admitted immediately, the median wait time for in-patient treatment in a medical centre is a little under four weeks.

All medical centre treatment is free of charge along with drugs administered, surgical consumables and appliances issued or loaned. Emergency treatment (accident and emergency and critical care) is also free of charge. A triage nurse prioritises all patients on arrival. Emergency treatment aims to treat patients within a maximum of 4 hours as part of Gosmed targets for emergency care. Gosmed also provides end of life palliative care in the form of palliative care specialist nurses. This, too, is included in provided service at a minimal charge to citizens.

Gosmed maintains a protocol of utilisation management, ordering only those tests and scans on initial presentation that are absolutely necessary for the case on hand. Additional or more advanced testing and scanning can be requested as is judged vital and more information becomes available. The exception is serious cases in accident and emergency, where a much more vigorous screening can be needed to help isolate and identify troubles as early as possible. In this way, course of care is maintained while costs are kept down, avoiding superfluous procedures and the risk of overtreatment. This performs a triple function - it helps eliminate unnecessary procedures, reduces patient discomfort, and ensures that taxpayer funding is responsibly used.

Direct-to-consumer product advertising (DTCPA) of prescription medications or treatments of any kind is forbidden by national law. Similarly, ADR law forbids any marketing of medicines or healthcare products to medical centres, clinics, or medical professionals.

In the event of an accident, or if a citizen requires emergency medical attention, all they or someone with them needs do is dial 999 from any telephone. The emergency dispatch operator that answers will take the caller's name, their current address, and a brief description of what has happened or is happening. An ambulance will be dispatched immediately, along with police and fire brigade support if needed. Once on site, paramedics will quickly evaluate the situation, attempt to stabilise the patient, and provide any needed assistance while on the way to the nearest medical centre.

Medical care operations

Through Gosmed, all clinics, polyclinics, and medical centres in the country operate under a series of universal protocols designed to ensure all personnel across the national healthcare network are working on the same system. These protocols touch on a broad range of matters and are compiled into the Handbook of Standardised Transaction Protocols in Healthcare (Справочник по стандартизированным протоколам операций в здравоохранении).

Accident & emergency

Every medical centre in the ADR has an accident & emergency (A&E) department. It is responsible for handling the acute care of patients who present without prior appointment, either by their own means or via an ambulance. Due to the unplanned nature of patient attendance, the department must provide initial treatment for a broad spectrum of illnesses and injuries, some of which can be life-threatening and require immediate attention. This department of every medical centre is open all day, every day. A smaller, separate section of the department is dedicated solely to geriatric (age 70 and older) patients, and another is reserved for juvenile (age 15 and under) patients.

Every accident and emergency department depending on size has between four and twelve trauma suites, where more seriously injured or ill patients can be treated separately. Additionally, there will be between two and seven dozen treatment cubicles, each of which is walled in with windows on all sides, where more patients whose conditions are less serious can be attended to. As necessary, patients can be moved from one to the other. A central nursing station will co-ordinate the department's activities throughout each shift. Every medical centre in the ADR maintains a standing policy of seeking to minimise patient wait times in accident & emergency. On average, no citizen waits longer than three hours. During this time, anyone in waiting will be offered water, tea, or coffee and access to light snacks. A nurse and two orderlies are on duty at the triage desk at all times. Whenever a paramedic crew is bringing a patient in, a tone sounds in the department alerting staff that a trauma is incoming.

Alert Codes

Alert codes are coded messages announced over the public address system of a medical centre to alert staff to various classes of on-site situations or emergencies. The use of these codes is intended to convey essential information quickly and with minimal misunderstanding to staff while preventing stress and panic among visitors. These codes are printed on the back of the access badges worn by all medical centre staff for ready reference.

Whenever certain codes are called, they will be followed by a floor and room number. In the case of a code blue, every examination room, patient room, the trauma suites and treatment cubicles in the accident and emergency department, the patient care cubicles in the critical care department, and each scanning room in diagnostic imaging have an emergency alert button on the dado panel on the wall above the patient bed - or on a small panel by the door - which will sound an alert chime and an automated voice will call the code, floor and room/cubicle number. Also, if a patient's vitals begin to drop dangerously low, their biobed will automatically sound an alert. Each floor has a dedicated code blue team that will respond when the code is sounded.

Code blue - heart or respiration stops (an adult or child’s heart has stopped or they are not breathing)
Code brown - severe weather alert
Code clear - announced when emergency is over
Code grey - combative person (combative or abusive behavior by patients, families, visitors, staff or physicians)
Code orange - hazardous spills alert (a hazardous material spill or release; unsafe exposure to spill)
Code pink - child abduction alert (medical centre goes on lockdown, security and local police are alerted, extremely rare)
Code red - fire alert
Code silver - weapon or hostage situation (very rarely called)
Code white - pediatric emergency (includes neonatal or obstetrical emergencies)
Code black - medical centre emegency services are at capacity; area emergency response units are directed to reroute A&E patients to other medical centres
External triage - external disaster (emergencies impacting hospital including: mass casualties, severe weather, large-scale power outages, and nuclear, biological, or chemical incidents)
Internal triage - internal emergency (internal emergency in multiple departments including: computer network down, major plumbing problems, and power or telephone outage)
Rapid response team - medical team needed at bedside (a patient’s medical condition is declining and needs an emergency medical team at the bedside) prior to heart or respiration stopping

Patient accommodation

Patients will be housed in the medical centre during an inpatient stay in one of two forms of accommodation - a ward, or a private room. The former will be a larger room with beds for twelve patients in individual cubicles separated by light walls with frosted plexiglass and a curtain that can be drawn to cover the entrance. The latter are individual rooms with a single bed. In both cases, a dado panel built into the wall above the head of the bed has an oxygen access port, a vacuum access port, and a Code Blue alert button. A compartment built into the wall below the dado panel in private rooms, A&E cubicles, and critical care cubicles contain a standard life support module to support the patient's breathing and blood oxygenation. A metal rack suspended from a ceiling mounted track over the head of the bed allows IV bags to be connected as needed. A central line, linked to the IV module, allows certain medications to be administered to the patient from a central supply located in a secured room at the nurses station.

The beds in each ward and private room have a grid of highly sensitive sensors built into the surface the patient lays on that allow it to monitor a patient's heart and brain activity, respiratory rate, blood oxygenation, and pulse rate. This minimises the need for invasive pads or other attachments on a patient. The beds in patient wards and individual rooms are likewise equipped. A monitor set into the wall above the head of the bed displays these measurements for doctors and nurses; a similar display in a monitor bank at the nurses station shows the same information, allowing continuous monitoring of patients. A control panel that folds out from the wall just below the monitor in each room or cubicle allows doctors to order medicines, treatments, scans, and other things a patient needs. These orders are sent directly to the nurses station, and a record of these orders is also kept in the patient's treatment file for their visit. These beds are also used in the trauma suites and treatment cubicles of the A&E department, and the cubicles of the critical care department.

Power and utility

Every medical centre in the ADR is equipped with its own dedicated primary generator and two backup generators. This ensures that the facility always has the power it needs to continue operations in the event of municipal grid trouble. In the event of severe weather or other situations, the medical centre will disconnect from the municipal grid and switch over to its primary generator. In the event it fails, the backups kick in within a few seconds, reducing potential problems. Similarly, each medical centre has its own dedicated water purification system to provide additional filtration to the facility supply. HVAC systems in each medical centre are designed so that every floor has its own, dedicated lines and returns, that in the event of an emergency specific floors can be cut off if necessary. The accident and emergency and critical care departments likewise are on their own, dedicated lines. This system is equipped with specialised biofilters and air purification to reduce the risk of airborne pathogens and retain necessary environmental control.

Staff uniform

All Gosmed personnel wear a specific uniform based upon their role within the healthcare system. These uniforms are designed to allow other staff, patients, and visitors to easily identify them. Consulting doctors (known as attendings in other nations) wear surgical green coloured scrubs with a full-length white lab coat. Resident doctors wear the same colour scrubs with a mid-length white lab coat. Intern doctors wear surgical green scrubs and a hip-length white coat. Nurses (registered and practical) wear wine coloured scrubs. Registered nurses are identified by the hip-length white coat they also wear. Orderlies wear pewter gray coloured scrubs.

All personnel, regardless of their role, wear a black nameplate on either their coat or scrub tunic (as appropriate) which has their name and medical postnominals on it in white. At the left side, the Gosmed logo is engraved into the nameplate. All doctors have their name and medical postnominals embroidered on the left breast of their white coat in black, with the Gosmed symbol to the left of their name.

Psychiatric care operations

Each medical centre in the nation has a small, dedicated psychiatric services unit, which houses the staff and facilities to provide care to citizens in need. There are rooms for therapy sessions and for psychiatric assessment and treatment. There are also temporary holding cells in the event a patient becomes combative and needs to be contained until the proper authorities can come and take them to a dedicated psychiatric centre.

In keeping with the medical ethics of the ADR, psychiatric specialists approach all patients by following the “moral imperative”, which is loosely describe as, “You come to us seeking help. We are here and willing to help. We will do everything we can to assist you.” Patients are treated with respect, patience, and compassion. They are encouraged to share their troubles, talk through them, and examine alternatives and options for helping to minimise their discomfort. Psychiatric centres offer one-on-one therapy sessions with an assigned counselor, consisting of one or more sessions a week, as is considered appropriate.

Psychiatric centres

A full-service facility that provides only psychiatric care is known as a psychiatric centre. These facilities are dedicated to providing the more focused therapeutic care citizens with serious disorders require.

Like medical centres, psychiatric centres are designed with an open, spacious layout, are well-lit, and decorated with gentle pastel colours. Patient rooms are simple but comfortable, and all patients receive three meals a day. An on-site doctor and small team of nurses provide immediate medical care and can arrange transport to a medical centre in emergencies. During intervals between therapy sessions, patients are encouraged to enjoy the amenities and entertainment of the commons room, take part in regularly scheduled activities, or walk the gardens. Patients can request the day's newspaper or various magazines or books from the on-site library if they wish. Specially trained orderlies on site provide assistance to patients or staff when needed. All treatment is thoughtful and humane; absolutely no violence or abuse is tolerated.

Psychiatric centres are divided into two types - general units and secure units. The vast majority are the former, which focus on making life as normal as possible for patients while continuing treatment to the point where they can be discharged. Those patients who receive medication are not permitted to hold their own medicines, which are provided at a regular time every day. Patients can freely walk the grounds and floors, and enjoy the various activities and amenities offered. The latter type, secure units, are high-security facilities intended to house those who present considerable danger to themselves or the public, are suicidal, or experiencing a severe psychiatric break. Each secure unit has a crisis stabilisation unit where those brought in during severe distress are helped with immediate care prior to being assigned a room and a more extensive treatment assessment being drawn up.

There are eight high-security psychiatric centres in the ADR, each with a six-province catchment area, that contain and treat the most severe and dangerous cases. These facilities have all of the same standard security in place as at regular psychiatric facilities, but with additional redundant features. These include higher walls, perimeter watchtowers, more extensive camera and motion sensor networks, a larger on-site security contingent, and at least one dedicated armed security response teams (ASRT). These facilities have stricter response protocols for combative incidents, and while violence or abuse are still not tolerated, more aggressive tactics for restraining and subduing patients are used if necessary. Unlike regular psychiatric centres, visitors are not permitted at the high-security facilities, and a sign on the security building at both the main gate and services gate will read - "МАКСИМАЛЬНАЯ БЕЗОПАСНОСТЬ – АБСОЛЮТНО НИКАКИХ ПОСЕТИТЕЛЕЙ" (MAXIMUM SECURITY - ABSOLUTELY NO VISITORS).

Notes