ICU Management & Practice, Volume 16 - Issue 3, 2016

Critical Care in Brazil

Brazil is the largest country in South America, and ranks fifth in the  ‏list of the most populous countries, with a population of approximately ‏209 million people (84% urban). It is a large country with ‏many challenges that affect the healthcare sector, such as economic ‏inequalities, and the demographic transition with an ageing population ‏(>10% older than 60%), the result of diminishing birth rates and ‏an increased life expectancy of 74 years (World Health Organization ‏2015). Despite the existence of universal coverage, 25% of the population ‏is covered by private insurance.

 

ICU Beds Capacity and Distribution

 

There are significant disparities when it comes ‏to hospitals and intensive care unit (ICU) beds. ‏Brazil has approximately 6400 hospitals, 69% ‏of which are private. Only 35% of hospital beds ‏are public, although the public sector also has ‏access to a substantial number of private beds ‏through contracts (Paim et al 2011; Cadastro ‏Nacional de Estabelecimentos de Saude 2016; ‏Instituto Brasileiro de Geografia e Estatística ‏2016).

 

There are approximately 36,000 ICU beds ‏in Brazil. Although this is one of the largest ‏number of ICU beds in the world per population, ‏its distribution in geographic terms or ‏by public or private hospital is heterogeneous. ‏There are 25 ICU beds per 100,000 inhabitants ‏and 7.6 public ICU beds per 100,000 inhabitants, ‏rates that on average are close to most ‏European countries (Rhodes et al 2012; Instituto ‏Brasileiro de Geografia e Estatística 2016). ‏However, distribution ranges from fewer than ‏3 beds per 100,000 inhabitants in some states ‏in the Northern region to more than 20 beds ‏per 100,000 inhabitants in the Southeast states ‏(Rhodes et al 2012, IBGE 2016).

 
Brazilian Critical Care Society

 

The Brazilian Critical Care Society (Associação ‏de Medicina Intensiva Brasileira - AMIB amib.org.br) plays a major role in the specialty. ‏Founded in 1980, it is the sole provider of ‏board examinations for specialists. There are ‏currently 5,797 physicians that specialise in ‏adult critical care and 1,539 in paediatric critical ‏care. There are currently 44 active centres ‏running critical care residency programmes ‏(38 adult, 5 paediatric) and in 2016 there are ‏234 physicians training in these centres. The ‏society’s educational arm is a rich source of ‏information and training through its website ‏as well as through local events. It provides ‏hundreds of courses per year and holds an ‏annual congress with 5,000 attendees. Among ‏books, consensus and other publications, a ‏highlight is the Brazilian Journal of Intensive Care ‏(rbti.org.br), a Pubmed/Medline indexed ‏medical journal published jointly with the ‏Portuguese Society of Critical Care in English, ‏Portuguese and Spanish.

 

Quality of Care
 

The National Health Surveillance Agency ‏(ANVISA) is responsible for regulatory rules ‏for ICU care organisation. The Health Ministry ‏defines the public policy and ANVISA is responsible ‏for surveillance, inspection and control ‏of quality of care and organisational aspects ‏throughout the country. The rules and criteria ‏for opening an ICU and to classify its ability to ‏care for patients presenting different severity ‏levels (from I to III) are published in a document ‏known as RDC No. 07 (National Health ‏Surveillance Agency, Ministry of Health 2010), ‏which determines the minimal requisites ‏for ICU functioning, including the requirements ‏for healthcare services inside the ICU ‏and inside the hospital structure, equipment, ‏monitoring tools and quantitative and qualitative ‏composition of the medical and healthcare ‏allied professional teams. All ICUs require ‏full presence of medical staff 24/7. A boardcertified ‏intensivist should be the responsible ‏ICU physician, and at least one board-certified ‏physician should be in charge of patient care ‏during the day. Night shifts can be covered by ‏non-board certified professionals. Reimbursement ‏is affected by classification based on this ‏document, and level III units receive higher ‏values than level I and II.


See Also:
Study: Brazil QI Intervention Did Not Reduce Mortality 


Despite these requirements, unfortunately ‏some units outside the main cities in the South ‏and Southeast regions still lack board-certified ‏professionals, and in these settings telemedicine ‏regulation could be an important measure ‏to improve quality of care.

 

Recent data from the Organizational Characteristics ‏in Critical Care (ORCHESTRA) study ‏(Soares et al. 2015) showed that only 21% of ‏units had the presence of a board-certified ‏intensivist 24/7, although this factor was not ‏associated with better outcomes. In this study, ‏better nurse-patient ratio was associated with increased ICU efficiency. The only organisational ‏characteristic associated with better ‏outcomes was the number of care protocols.

 

The effects of protocols were consistent across ‏subgroups including surgical and medical ‏patients as well as different severity levels. ‏In addition, results suggest that collaborative ‏multidisciplinary work among ICU care ‏providers impacts favourably on the patients’ ‏outcomes, since hospital mortality was lower ‏in ICUs where protocols were jointly managed ‏by different care providers.

 

Another relevant aspect of ICU regulation in ‏Brazil, is the need to collect and report quality ‏indicators to ANVISA on a regular basis. Use ‏of severity-of-illness assessment tools (e.g. ‏Acute Physiology and Chronic Health Evaluation ‏[APACHE-II] or Simplified Acute Physiology ‏[SAPS 3], the latter recommended by ‏AMIB), standardised mortality rate, occupancy ‏rate, central line-associated bacteraemia, or ‏ventilator-associated pneumonia are examples ‏of obligatory variables. AMIB has developed ‏a project (UTIs Brasileiras – utisbrasileiras.com/en) in partnership with EPIMED® to ‏provide access to an online performance monitoring ‏tool in which this information can be ‏collected and assessed for performance evaluation ‏and benchmarking among different ICUs ‏throughout the country. EPIMED® Monitor ‏System is a Brazilian commercial cloud-based ‏registry for quality improvement (epimedsolutions.com/en), performance evaluation, and ‏benchmarking purposes that has more than ‏1,000,000 Brazilian patients included. This is ‏a big data opportunity to generate knowledge ‏and better understand critical care in Brazil.

 

Research Networks

 

The critical care scenario is changing quickly ‏in Brazil and new challenges are arising, ‏including translating investments in structure, ‏education and research into better healthcare ‏and reducing the mortality that is still unacceptably ‏high for many types of severe acute ‏illnesses in our country (BRICNet (Brazilian ‏Research in Intensive Care Network) 2014). ‏To respond to these demands, it is crucial to ‏organise regional research networks assessing ‏these critical issues in the care of critically ill ‏patients. Brazil hosts initiatives on research, ‏such as the Latin American Sepsis Institute ‏(ILAS- ilas.org.br), the Brazilian Research in ‏Intensive Care Network (BRICNet – bricnet.‏org/english) and AMIB-Net (Comitê Científico ‏da BRICNet 2014).

 

AMIB-Net is a network, run by the Brazilian ‏Critical Care Society (AMIB) since 2009, ‏that supports and runs observational studies ‏focusing on education and professional development. ‏It reaches almost every ICU professional ‏throughout the country and has developed ‏several surveys and identified areas of ‏interest and geographical particularities for ‏future projects in Brazil.

 

The Brazilian Research in Intensive Care ‏Network (BRICNet) is an active and independent ‏organisation. Collaboration with ‏international research networks is intense ‏and has allowed many studies to enrol a large ‏number of ICU and patients in Brazil. Since ‏2007 BRICNet has been able to endorse and ‏run several multicentre observational studies as ‏well as support local and international studies ‏and investigators. Their results have helped us ‏to improve current knowledge on the epidemiology ‏and organisation of critical care in ‏Brazil. Recent initiatives resulting in studies ‏most relevant to Brazil include the Checklist- ‏Trial (Writing Group for the CHECKLIST-ICU ‏Investigators and the Brazilian Research in ‏Intensive Care Network (BRICNet) 2016) and ‏the ORCHESTRA Study (Soares et al 2015), ‏amongst several others supported by this ‏network.

 

The Latin America Sepsis Institute (ilas.org.‏br) is a reference in Brazil for clinical studies, ‏continuous medical and allied healthcare ‏professions education, and quality improvement ‏initiatives implementation in sepsis. ‏This network has included more than 40,000 ‏septic patients since 2004 and its projects aim ‏to improve quality of care and knowledge on ‏sepsis in Brazil and Latin America.

 

Challenges and Opportunities
 

There are of course many challenges and opportunities ‏in the field of critical care medicine in ‏Brazil. These challenges represent enormous ‏opportunities for improvement in the delivery ‏of care, and present an enormous task that can ‏only be successful if all stakeholders, policy ‏makers and society acknowledge them and ‏work on sustainable actions and long-term plans.

The first challenge is to provide universal ‏and timely access to critical care. This is especially ‏important to care not only for the daily ‏challenges such as sepsis, trauma and respiratory ‏failure, but also for emerging threats that ‏include Zika and Dengue (Bozza and Salluh ‏2010; Bozza and Grinsztejn 2016).

 

Austin et al. (2014) evaluated acute care ‏services supply in seven cities of diverse ‏economic background, including a city in ‏Brazil (Recife). This demonstrated that urban ‏acute care services vary substantially across ‏economic regions and economic differences ‏play only a partial role. Thus, in some cities, ‏despite adequate provision of ICU beds, there ‏was substantial difference in mortality rates ‏(Austin et al 2014). Certainly, several aspects ‏seem to play a role in the gap observed in ‏mortality rates in sepsis (Kaukonen et al. 2014; ‏Conde et al. 2013; Machado et al. 2013)and ‏acute respiratory failure (Azevedo et al. 2013) ‏between low and middle-income countries ‏as compared to high-income countries. One ‏is the incomplete translation of evidence to ‏practice as observed by the relatively low ‏adherence to best practices such as low tidal ‏volume (Azevedo et al. 2013) and light sedation ‏(Writing Group for the CHECKLIST-ICU ‏Investigators and the Brazilian Research in ‏Intensive Care Network (BRICNet) 2016). ‏However, a recent Brazilian study made clear ‏that when protocols and other feasible organisational ‏factors are in place, outcomes are ‏improved (Soares et al 2015). Another study ‏showed that checklists may improve adherence ‏to some of the best practices and improve the ‏safety climate and teamwork (Writing Group ‏for the CHECKLIST-ICU Investigators and the ‏Brazilian Research in Intensive Care Network ‏(BRICNet) 2016). Last, but not least, adequate ‏staffing patterns are to be established with ‏two main special focuses. The first is to make ‏specialists available for rural areas. Whilst this is ‏hard to achieve even in high-income countries ‏with continental dimensions technology can ‏help decrease the gaps with the use of telemedicine ‏and the availability of specialists for ‏remote consultation. The second is to increase ‏the nurse to bed ratio as well as the number ‏of specialised nurses, as they play a key role in ‏the implementation of protocols and infection ‏control measures.

 

Conclusion

 

Critical care is a fast-evolving medical field in ‏Brazil that carries opportunities and challenges ‏as big as the continental dimensions of the ‏country. To address these challenges involvement ‏of the main stakeholders is crucial and ‏increased data on epidemiology as well as ‏clinical studies that tackle the aspects of translating ‏evidence to practice are urgently needed.

 

Conflict of Interest

 

Jorge Salluh is founder and shareholder of ‏Epimed Solutions. Thiago Lisboa declares that ‏he has no conflict of interest.


References:

Azevedo LC, Park M, Salluh JI et al. (2013) Clinical outcomes of patients requiring ventilatory support in Brazilian intensive care units: a multicenter, prospective, cohort study. Crit Care, 17(2): R63.

PubMed ↗


BRICNet (Brazilian Research in Intensive Care Network) (2014)

Research networks and clinical trials in critical care in Brazil: current status and future perspectives. Rev Bras Ter Intensiva, 26(2):79-80.


Cadastro Nacional de Estabelecimentos de Saude (2016) [Accessed: 20 Jul 2016]  Available from http://cnes.datasus.gov.br


Conde KA, Silva E, Silva CO et al. (2013) Differences in sepsis treatment and outcomes between public and private hospitals in Brazil: a multicenter observational study PLoS One, 8(6): e64790.

PubMed ↗

 

Instituto Brasileiro de Geografia e Estatística (n.d.) Observatorio das cidades. [Accessed: 20 July 2016] Available from cidades.ibge.gov.br/xtras/fontes.php

 

Kaukonen KM, Bailey M, Suzuki S et al. (2014) Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000-12. JAMA, 311(13): 1308-16.

PubMed ↗

 

Machado FR, Salomão R, Rigato O et al. (2013) Late recognition and illness severity are determinants of early death in severe septic patients. Clinics (Sao Paulo), 68(5): 586-91.

PubMed ↗

 

Paim J, Travassos C, Almeida C et al. (2011) The Brazilian health system: history, advances, and challenges. Lancet, 377(9779): 1778-97.

PubMed ↗


Rhodes A , Moreno RP (2012) Intensive care provision: a global problem.Rev Bras Ter Intensiva, 24(4): 322-5.

PubMed ↗


Soares  M, Bozza FA, Angus DC et al. (2015) Organizational characteristics, outcomes, and resource use in 78 Brazilian intensive care units: the ORCHESTRA study. Intensive Care Med, 41(12): 2149-60.

PubMed ↗


Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet) (2016) Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: a randomized clinical trial. JAMA, 315(14): 1480-90.

PubMed ↗


Bozza FA, Salluh J. (2010) An urban perspective on sepsis in developing countries.

Lancet Infect Dis, 10(5): 290-1.

PubMed ↗


Bozza FA, Grinsztejn B (2016) Key points on Zika infection for the intensivist.

Intensive Care Med,42(9): 1490-2.

PubMed ↗


Austin S,  Murthy S, Wunsch H et al. (2014) Access to urban acute care services in high- vs. middle-income countries: an analysis of seven cities. Intensive Care Med, 40(3): 342-52.

PubMed ↗


National Health Surveillance Agency, Ministry of Health.  (2010) Resolução-RDC Nº 7, de 24 de Fevereiro de 2010. [Accessed: 8 September 2016] Available from www20.anvisa.gov.br/segurancadopaciente/index.php/legislacao/item/rdc-7-de-24-de-fevereiro-de-2010


World Health Organization (2015) Brazil: WHO statistical profile. [Accessed: 8 September 2016] Available from http://www.who.int/gho/countries/bra.pdf?ua=1



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