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

Collaborators

Tofani LFN (0000-0002-1092-2450)^* * Orcid (Open Researcher and Contributor ID). , Furtado LAC (0000-0001-7897-9739)^* * Orcid (Open Researcher and Contributor ID). and Chioro A (0000-0001-7184-2342)^* * Orcid (Open Researcher and Contributor ID). contributed to the conception and design of the study; acquisition, analysis and interpretation of the data; preparation of the manuscript and revision of the final version to be published. Andreazza R (0000-0002-3332-2183)^* * Orcid (Open Researcher and Contributor ID). , Nasser MA (0000-0001-8409-7265)^* * Orcid (Open Researcher and Contributor ID). and Bizetto OF (0000-0001-7839-8109)^* * Orcid (Open Researcher and Contributor ID). contributed to the conception and design of the study; acquisition, analysis and interpretation of the data; critical review of the manuscript and review of the final version to be published.

Respondent	RUE point of attention	Position/Function
G1C	Basic Health Unit (UBS)	Coordinator
G2C	Municipal SAMU	Director
G3C	Municipal SAMU	Coordinator
G4C	UPA	Administrative Coordinator
G5C	UPA	Manager
G6C	Municipal Hospital	Director of the Emergency Room
G7C	Home Care Service	Technical Nurse
G1H	Basic Health Unit (UBS)	Manager
G2H	UPA	Manager
G3H	Regional Samu	Coordinator
G1S	Basic Health Unit (UBS)	Manager
G2S	Home Care Service	Manager
G3S	Philanthropic Hospital	Technical Nurse
G1E	State University Hospital	Emergency Unit Coordinator
G2E	Regional State Hospital	Emergency Coordinator
G3E	Regional Regulation Center	Project Coordinator

I - expansion of access and reception of acute cases demanded to health services at all points of care, contemplating the risk classification and adequate and necessary intervention to the different diseases.

II - guarantee of universality, equity and integrality in the care of clinical, surgical, gyneco-obstetric, psychiatric, pediatric emergencies and those related to external causes (trauma, violence and accidents).

III - regionalization of emergency care with articulation of the various care networks and regulated access to health services.

IV - humanization of care ensuring the effectiveness of a user-centered model based on their health needs.

V - guarantee of implementation of a multiprofessional care model, shared by teamwork, established through clinical care practices and based on the management of lines of care.

VI - articulation and integration of the various health services and equipment, constituting health networks with connectivity between the different points of care.

VII - territorial action, definition and organization of health regions and care networks based on the health needs of these populations, their specific risks and vulnerabilities.

VIII - professional and managerial performance aimed at improving the quality of care through the development of coordinated, continuous actions that seek the integrality and longitudinality of health care.

IX - monitoring and evaluation of the quality of services through performance indicators that investigate the effectiveness and resoluteness of care.

X - interfederative articulation between the various managers, developing solidarity, responsible and shared action.

XI - participation and social control of users over the services.

XII - promotion, coordination and execution of strategic projects to meet collective health needs, of urgent and transitory nature, resulting from situations of imminent danger, public calamities and accidents with multiple victims, from the construction of regional and local risk maps and the adoption of protocols for prevention, attention and mitigation of events.

XIII - articulated regulation between all components of the Emergency Care Network, guaranteeing equity and integrality of care.

XIV - qualification of care through permanent education of SUS health teams in emergency care, in accordance with the principles of integrality and humanization.

Components	UBS	Samu 192	UPA 24h	Hospital	Home Care
UBS	x	“If it is an emergency service, we have to call SAMU. Then we refer the case to Samu, because today we don’t care about the service, we care about SAMU”. G1H “The team arrived to make the home visit, it was a nephropathic pregnant woman, which they were worried about. When they arrived, she was completely edematous and hypertensive, already with signs of kidney failure, and then we called SAMU”. G1C	“this flow, this connection, is not cool yet [...] They do not communicate with us. The patient who goes to the UPA every week because of peak pressure, should have been reported to us. Even if they refer this patient to us and he doesn’t come, they need to communicate to us that this patient is going there frequently”. G1H “We get a lot from there to here, and we really see a change. Before it was a very informal referral (...) today we have the computerized system and can already see the history of the patient who goes there [...] we are even doing work within the emergency department to identify the personnel who should be in primary care and are looking for emergency care”. G1S	“patients who leave the hospital are sent to UBS without any opinion. So, we end up not knowing what happened, what medicine he took, what happened, what kind of alteration he had, and this complicates a lot [... what I think is wrong today are these counter-referrals...] If I don’t look for this patient, what they did there, I don’t know how he evolved, if he was transferred to another hospital”. GH1 “With hospitals, we already have a lot of difficulty. We always had it [...] with the hospital, we have very little articulation or dialogue”. GC1	“Yes, these articulations happen quite a lot. [...] Sometimes, the SAD sends an e-mail, we find out via SAD; sometimes, the hospital, sometimes they already articulate the two things together. [...] it’s case by case, we don’t have anything systematic, organized for the case discussion meeting, but it’s not a difficult conversation”. G1C “We register via the system, but there is a separate form that is filled out according to the doctor’s assessment [...] the team makes evaluation, visits the house, and verifies if it really is with the SAD criteria or not. If it is, they receive it, and if it is not, it returns to the unit directing a possible treatment”. G1S
Samu 192	“they arrive there in the basic unit, the nurse has difficulty doing electro [...] there, the doctor looks, he begins anamnesis on the patient, but... you don’t know how to work with that”. G2C “UBS takes a little more work because it needs to close, and the doctor needs to leave”. G3C	x	“Connected, that’s how I say it, we have a very great proximity. So I know what’s going on in a 24-hour UPA. It’s much more finely tuned”. G2C	“I think this way: we know that the tertiary are all “exploding”, but we have to try, right? Sometimes I have patients with low or medium complexity that I don’t need to take to a tertiary hospital”. G3C “we’re not having much of a problem. More serious cases, we can also direct to the state”. G3H	“It demands a little. Do you want to know what demands more? It’s in death. For the doctor to go, make the finding [...] the home service went there, received the patient, and needs to take it somewhere, and we go there”. G2C
UPA 24h	“We have health centers nearby. We try to support each other, but the interaction is not... [...] when we give patients discharges, we give them a referral to the Health Center as well so that they can follow up [...] we see that the patient sometimes cannot get a place in the Health Center, he cannot get an appointment, and then he comes here [...] we have to get in touch with them and send them back [...] but this is not a frequent thing. There's not a specific channel”. G4C	“we have an excellent relationship with SAMU, SAMU really is a service of excellence [...] we see several serious patients, several patients who need a quick commute, we can do it, without loss". G5C	x	“when we can’t solve the cases here [...] we referred them to the central hospital”. G4C “between the UPAs and the Hospital, we are very united [...] there is a friendship between the coordinators. We created a very close bond, because there is always a meeting that one says they need something, the other answers, so there is a very close contact [...] with the WhatsApp group, then, the bond is even greater”. G2H	“there is the service, but we do not make this relationship. Here, we either discharge or hospitalize [...] saying that a case will be discharged and go to SAD is not routine”. GC4
Hospital	“We have a system, but it is chronic pathologies, such as hypertension, COPD. When we discharge here in the ward, you can immediately schedule at the Health Center [...] but the relationship needs to get closer, if only because nowadays there is a bi-parity. We have a Department of Health and an autarchy. So, it seems that there is a gap between primary care and urgency and emergency.” G6C	“The dialogue with SAMU has improved a lot [...] So, we use the normal and personal ways to solve things [...] we try to deflect cases. When it is full, I communicate the SAMU”. G6C “No, not even regional (SAMU). Today we use the service of the municipality. We call it 192, and then they do the removals, including in the houses [...] there are 196,000 inhabitants. We need it, right? But we don’t have it.” G3S	“we have the geography in our favor because the UPA is in front of out hospital. So, the surgeon can go there to see, the orthopedist, the vascular and the neurosurgeon”. G3S “the idea is great, to actually take a patient out of a UPA. You put it in the Hospital and pick up a patient in the Hospital and send them home right away. The only problem is that it always goes wrong [...] as long as the big doctors aren’t in charge, it’s going to take a little while for us to get it done”. G1S	x	“One thing that works really well is our SAD. Chronic patients who need home care. We manage to de-hospitalize many patients. This is a very positive factor for us”. G6C
Home Care	“with UBS, we made a plan [...] the UBS did not know the SAD. A work of approximation begins, visiting all the UBSs, asking for a team meeting space, to introduce themselves and present what SAD was, the flow [...] we had a lot of articulated case discussion afterwards”. G7C	“SAMU? Only in some cases. We don’t have a discussion, a think-along protocol, right? We need SAMU at some point, when the family opts for the death to be at home [...] this conversation is very difficult”. G7C	“It is done in everyday life. There are some UPAs you can get it [...] it is case-by-case in that sense. And also heterogeneous because, in other UPAs , you ask for support for the palliative patient, and they say: “No, there’s nothing to do with the palliative” [...] there is no articulation, we do not sit down, we do not have news”. G7C	“There was an attempt for us to try to do things together with the hospital network, which are the visits, to meet the patient in bed still [...] we made about three visits, but the information is lost inside the hospital [...] The thing in the hospital network is tougher, more hierarchical”. G7C	x
Home Care	“in the UBS, we notice a great demand for chronic cases [...] we have a referral protocol. There is a referral form filled out by the doctor with a current case report and the necessary documents”. G2S	“it is a hindering factor, because we don’t have SAMU. We don’t have that service. We have the sanitary transport and the fire department”. G2S	“It depends on the quality of each professional. It’s hard say that there is a protocol. We don’t have that kind of referral [...] there are professionals who prefer to report in writing [...] The telephone contact, I think, works better, usually from doctor to doctor [...] we have reports from family members that sometimes the emergency room doctor does not even pick up the letter to read”. G2S	“at discharge, the hospital verifies that the patient is stable and already triggers us. Sometimes, the patient is still hospitalized, already makes contact with us and already directs the referral [...] especially patients who go to the emergency room for nasoenteral tube placement. Usually, they all refer to us because our sector has the Nutrition Service”. G2S	x

[1] Conflict of interests: non-existent

Brasil

Brasil

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

ABSTRACT