[Implementation of the Mobile Emergency Medical Service in Brazil: action strategies and structural dimension]

[Regulatory aspects and measures of the Emergency Care Network: a game of disputes between the public and private interests]

The study analyzes regulatory aspects and measures as social production in the Emergency Care Network (RUE) of two health regions. This is a multiple case study of qualitative character, performed via 61 interviews with public administrators, users, and health services managers. The analysis had as theoretical reference the Theory of Social Production. We identified professional, lay, clientelistic, and governmental regulatory measures, in the systemic aspects, of the services and of access. The main results point to regulatory flows produced by movements of various social actors, with emphasis on the action of representatives of hospital service providers, especially private ones, characterizing the proposal of another regime: market regulation. We emphasize the limits and powers of arrangements, such as hospital and the Mobile Emergency Care Service (SAMU) regulation centers, the internal hospital regulation centers, and the use of WhatsApp. Health regulation in RUE consists of complex, contradictory, and conflicting social processes, whose flows are produced at the limit between the public and private interests.

Facilidades e entraves da referência em unidade de pronto atendimento

Resumo Objetivo descrever, na perspectiva de enfermeiros e médicos, as facilidades e os entraves da referência em uma Unidade de Pronto Atendimento. Método estudo descritivo, qualitativo, realizado em uma Unidade de Pronto Atendimento de um município de Santa Catarina, Brasil. Participaram sete enfermeiros e 23 médicos. Os dados foram coletados por meio de entrevista individual semiestruturada e analisados mediante a técnica do Discurso do Sujeito Coletivo. Resultados as facilidades envolveram: ter serviços de referência especializados; gravidade do paciente; atendimento em “vaga zero”; boa relação entre os profissionais dos serviços de urgência e a empatia. Dentre os entraves, estavam: contato difícil por telefone com os hospitais e a superlotação destes; dificuldade para conseguir transporte, sobretudo, para paciente com situação clínica estável e a falta de ambulância do município. Conclusão e implicações para a prática as facilidades da referência potencializam o atendimento às urgências, porém, os entraves, referentes à vaga hospitalar e ao transporte, podem comprometer a integralidade e a continuidade do cuidado, necessitando de melhorias na atenção à saúde em rede.

Emergency and Urgent Health Care Network on scene: contingencies and production of care

ABSTRACT This study aims to analyze the possible transformations in health care management and production processes, in the context of practice, based on the Emergency and Urgent Health Care Network (RUE) policy. The research has a qualitative character and is characterized as a case study. Interviews were conducted with 16 health service managers in four municipalities of different population sizes. The material was analyzed with reference to the context of the Public Policy Cycle Approach practice. It is observed that the RUE is not recognized as a public policy, although some of its elements are identified, such as the implementation of Emergency Care Units, protocols, risk classification, new care technologies, regulatory arrangements, and lines of care. Looking at the ‘RUE on scene’ mainly points to three issues: the relationship between primary care and emergency doors in meeting spontaneous demand; the medical regulation of Mobile Emergency Care Service (SAMU), as a promoter of access and quality; and the (dis)continuity in health care. There is evidence of live movements and productions induced by the policy that qualify health care in urgent and emergency situations. However, inequities are maintained or produced, and the need for articulation between network components, although evoked, translates into fragile and non-regular connections.

A Rede de Atenção às Urgências e Emergências em cena: contingências e produção de cuidado

RESUMO Este estudo tem por objetivo analisar as transformações nos processos de gestão e produção do cuidado em saúde, no contexto da prática, a partir da política da Rede de Atenção às Urgências e Emergências (RUE). A pesquisa tem caráter qualitativo e caracteriza-se como estudo de caso. Foram realizadas entrevistas com 16 gerentes de serviços de saúde em três municípios de diferentes portes populacionais. O material foi analisado tendo como referência o contexto da prática da Abordagem do Ciclo de Políticas. Observa-se que a RUE não é reconhecida enquanto política pública, embora sejam identificados alguns de seus elementos, como a implantação de Unidades de Pronto Atendimento, protocolos, classificação de risco, novas tecnologias assistenciais, arranjos regulatórios e linhas de cuidado. O olhar para a ‘RUE em cena’ aponta para três questões: a relação entre a atenção básica e as portas de urgência no atendimento à demanda espontânea; a regulação médica do Serviço de Atendimento Móvel de Urgência (Samu), enquanto promotora de acesso e qualidade; e a (des)continuidade no cuidado em saúde. Há evidências de movimentos e produções vivas induzidas pela política que qualificam o cuidado em saúde em situações de urgência e emergência. Entretanto, iniquidades são mantidas ou produzidas, e a necessidade de articulação entre os componentes em rede, embora evocada, traduz-se em conexões frágeis e não regulares.

Emergency medicine in Brazil: historical perspective, current status, and future challenges

Background

Emergency medicine (EM) in Brazil has achieved critical steps toward its development in the last decades including its official recognition as a specialty in 2016. In this article, we worked in collaboration with the Brazilian Association of Emergency Medicine (ABRAMEDE) to describe three main aspects of EM in Brazil: (1) brief historical perspective; (2) current status; and (3) future challenges.

Main text

In Brazil, the first EM residency program was created in 1996. Only 20 years later, the specialty was officially recognized by national regulatory bodies. Prior to recognition, there were only 2 residency programs. Since then, 52 new programs were initiated. Brazil has now 54 residency programs in 16 of the 27 federative units. As of December 2020, 192 physicians have been board certified as emergency physicians in Brazil. The shortage of formal EM-trained physicians is still significant and at this point it is not feasible to have all Brazilian emergency care units and EDs staffed only with formally trained emergency physicians. Three future challenges were identified including the recognition of EM specialists in the house of Medicine, the need of creating a reliable training curriculum despite highly heterogeneous emergency care practice across the country, and the importance of fostering the development of academic EM as a way to build a strong research agenda and therefore increase the knowledge about the epidemiology and organization of emergency care.

Conclusion

Although EM in Brazil has accomplished key steps toward its development, there are several obstacles before it becomes a solid medical specialty. Its continuous development will depend on special attention to key challenges involving recognition, reliability, and research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12245-021-00400-6.

Increased Home Death Due to Cardiopulmonary Arrest in Times of COVID-19 Pandemic

Fundamento

As doenças cardiovasculares constituem um grupo importante de causas de morte no Brasil. As doenças isquêmicas do coração são as principais causas de parada cardiorrespiratória, levando a um impacto na mortalidade devido às doenças cardiovasculares no sistema de saúde.

Objetivo

Avaliar o número de óbitos domiciliares por parada cardiorrespiratória notificados pelo Serviço de Atendimento Móvel de Urgência (SAMU) em março de 2018, 2019 e 2020.

Métodos

Trata-se de um estudo observacional realizado a partir da análise de dados de mortalidade por parada cardiorrespiratória de cidadãos atendidos pelo SAMU em Belo Horizonte, Minas Gerais, Brasil. Foram analisadas as características sociais e clínicas e as informações de ocorrência. Foi avaliada a taxa de mortalidade por parada cardiorrespiratória em relação ao número total de atendimentos. Foi considerado um nível de significância de 95%.

Resultados

Houve um aumento nos óbitos domiciliares por parada cardiorrespiratória em março de 2020, em comparação com março de 2018 (p < 0,001) e março de 2019 (p = 0,050). Dos óbitos relatados em 2020, 63,8% dos pacientes tinham 60 anos ou mais; 63,7% das ocorrências foram à tarde e aproximadamente 87% dos casos de parada cardiorrespiratória notificados apresentavam comorbidades clínicas, com hipertensão arterial sistêmicas e parada cardíaca correspondendo a 22,87% e 13,03% dos casos relatados, respectivamente. A maioria da amostra avaliada deste estudo não teve acompanhamento médico (88,7%).

Conclusão

Considerando o aumento do número de óbitos, sugerimos reflexões e reajustes quanto ao monitoramento das doenças crônicas não transmissíveis durante a pandemia, bem como melhorias na vigilância dos óbitos. (Arq Bras Cardiol. 2021; 116(2):266-271)

Mortality Due to Acute Myocardial Infarction in Brazil from 1996 to 2016: 21 Years of Disparities in Brazilian Regions

Fundamento:

O infarto agudo do miocárdio (IAM), principal causa de morte no Brasil, apresenta disparidades regionais nas tendências temporais das taxas de mortalidade dos últimos anos. Estudos anteriores de tendências temporais não fizeram correção para os códigos-lixo de causas de mortalidade, o que pode ter enviesado as estimativas.

Objetivo:

Analisar as desigualdades regionais e por sexo na tendência de mortalidade por IAM no Brasil no período de 1996 a 2016.

Métodos:

Estudo de séries temporais de 21 anos (1996 a 2016). Os dados são do Sistema de Informações sobre Mortalidade (SIM) e das estimativas populacionais do Instituto Brasileiro de Geografia e Estatística (IBGE). Foram feitas correções de óbitos por causas mal definidas, códigos-lixo e sub-registro. As séries temporais desagregadas por grandes regiões, sexo, capitais e interior foram analisadas utilizando a técnica de regressão linear segmentada por Jointpoint. O nível de significância estatística adotado foi de 5%.

Resultados:

No período, a mortalidade diminuiu mais acentuadamente no sexo feminino (–2,2%; IC 95%: –2,5; –1,9) do que no masculino (–1,7%; IC 95%: –1,9; –1,4), e mais nas capitais (–3,8%; IC 95%: –4,3; –3,3) do que no interior (–1,5%; IC 95%: –1,8; –1,3). Foram verificadas desigualdades regionais com aumento para homens residentes no interior do Norte (3,3; IC 95%: 1,3; 5,4) e Nordeste (1,3%; IC 95%: 1,0; 1,6). O nível de significância estatística adotado foi de 5%. As taxas de mortalidade após correções, principalmente pela redistribuição dos códigos-lixo, apresentaram expressiva diferença em relação às estimativas sem correções.

Conclusões:

Embora a mortalidade por IAM apresente redução no Brasil nos últimos anos, essa tendência é desigual segundo região e sexo. Desse modo, as correções dos números de óbitos são essenciais para estimativas mais fidedignas.

Work weaknesses and potentials: perception of mobile emergency service nurses

OBJECTIVES

to know nurses' perceptions about their work process in a Mobile Emergency Care Service.

METHODS

qualitative study conducted with 12 nurses whose speeches were submitted to Content Analysis.

RESULTS

there are weaknesses related to overload of activities, numerous functions, indirect supervision, risk situations, difficulties in relationship with hospitals, lack of vehicles and professionals, inappropriate places to provide care and lack of knowledge of the population about urgent and emergency care. Potentials were associated with effective interpersonal relationships, continuing training, security when arriving at the place of care, care protocol and taste for what you do.

FINAL CONSIDERATIONS

the identified weaknesses need to be noted by managers and nurses. Thus, they would seek to establish actions to diminish them and maximize potentials, which could improve patient care as well as reduce occupational risks and, in turn, promote workers' well-being.

Effectiveness of the Mobile Emergency Medical Services (SAMU): use of interrupted time series

OBJECTIVE

To evaluate the performance of the Mobile Emergency Medical Services (SAMU) in the ABC Region, using myocardial infarction as tracer condition.

METHODS

The analysis of interrupted time series was the approach chosen to test immediate and gradual effects of the intervention on the study population. The research comprised adjusted monthly time series of the hospital mortality rate by myocardial infarction in the period between 2000 and 2011. Data were extracted from the Mortality Information System (SIM), using segmented regression analysis to evaluate the level and trend of the intervention before and after its implementation. To strengthen the internal validity of the study, a control region was included.

RESULTS

The analysis of interrupted time series showed a reduction of 0.04 deaths per 100,000 inhabitants in the mortality rate compared to the underlying trend since the implementation of the Emergency Medical Services (p = 0.0040; 95%CI: -0.0816 - -0.0162) and a reduction in the level of 2.89 deaths per 100,000 inhabitants (p = 0.0001; 95%CI: -4.3293 - -1.4623), both with statistical significance. Regarding the control region, Baixada Santista, the difference in the result trend between intervention outcome and post-intervention control of -0.0639 deaths per 100,000 inhabitants was statistically significant (p = 0.0031; 95%CI: -0.1060 - -0.0219). We cannot exclude confounders, but we limited their presence in the study by including control region series.

CONCLUSIONS

Although the analysis of interrupted time series has limitations, this modeling can be useful for analyzing the performance of policies and programs. Even though the intervention studied is not a condition that in itself implies effectiveness, the latter would not be present without the former, which, integrated with other conditions, generates a positive result. SAMU is a strategy that must be expanded when formulating and consolidating policies focusing on emergency care.

Epidemiological overview - 18 years of ICU hospitalization due to trauma in Brazil

OBJECTIVE

Assess the magnitude and trend of hospitalization rates due to traumatic injuries in intensive care units (ICU) in Brazil from 1998 to 2015.

METHODS

This is an ecological time-series study that analyzed data from the Hospital Information System. A trend analysis of hospitalization rates was performed according to diagnosis, sex and age using generalized linear regression models and Prais-Winsten estimation.

RESULTS

Rates were higher among male patients, but increased hospitalization due to trauma among female patients influenced the ratio between both sexes. Falls and transport accidents were the most frequent causes of trauma. The average annual growth was 3.6% in ICU trauma hospitalization rates in Brazil, the highest growth was reported in the North region (8%; 95%CI 6.4-9.6), among women (5.4%; 95%CI 4.5-6.3), and among people aged 60 years and older (5.5%; 95%CI, 4.7-6.3). The most frequent causes of trauma are falls (4.5%; 95%CI 3.5-5.5) and care complications (5.4%; 95%CI 4.5-6.3). On the other hand, the annual hospital mortality rate due to trauma in ICU is 1.7% lower, on average (95%CI 2.1-1.3).

CONCLUSION

An increase in ICU hospitalization rate due to trauma in Brazil may be the result of some factors, such as an increasing number of accidents and cases of violence, the implementation of pre-hospital care, and improved access to care, with more beds in ICU. In addition, population aging is another factor, as a greater increase in hospitalization was observed among people aged 60 years and older.

Integration between Primary Health Care and Emergency Services in Brazil: Barriers and Facilitators

Introduction:

Characteristics of primary health care and emergency services may hamper their integration and, therefore, reduce the quality of care and the effectiveness of health systems. This study aims to identify and analyse policy, structural and organizational aspects of healthcare services that may affect the integration between primary health and emergency care networks.

Theory and Methods:

We conducted a qualitative research study based on grounded theory that included: (1) interviews with 30 health care leaders; and (2) documental analysis of the summaries of Regional Interagency Committee meetings from two regions in the state of Sao Paulo, Brazil.

Results:

The integration between primary health and emergency care network is inefficient. The barriers that contributed to this situation are as follows: (1) policy: the municipal health department is responsible for providing primary health care and the regional health department provides emergency care, but there is a lack of space for the integration of services; (2) structural: distinct criteria for planning mechanisms; and (3) organizational: ineffective point of interaction between different levels of the health system.

Conclusions and discussion:

Our findings have implications for health management and planning in low-and middle-income countries (LMICs) with suggestions for interventions for overcoming the aforementioned barriers.