Brazil

BRAZIL

About

Capital – Brasilia
Land Size – 8,514,877 sq km
Population – 201,103,330
Language(s) – Portuguese (official and most widely spoken language)

Links

System Model

  • A combination of the Franco-German EMS system and the developing Anglo-American emergency medicine model, “creating a uniquely Brazilian approach to emergency care” (Tannebaum, 223)
    • Two divisions of Prehospital Care
      • Fixed locations
        • Basic Health Units
        • Family Health Program
        • Specialized Cllinics
        • Diagnosis & Therapy services
        • Non-hospital Emergency Care Units
      • Mobile Response
        • On-Scene Emergency Medical Response
        • Also provides psychiatric emergency assistance
  • “[US-style] Paramedics do not exist in Brazil because Brazilian law precludes nonphysicians from performing intubation, defibrillation, and other … ALS procedures” (Tannebaum, 225)
    • “No standards governing qualifications of EMS physicians, except that they must hold a valid state license to practice medicine” (Tannebaum, 225)
      • 1 BLS ambulance per 100,000 – 150,000 inhabitants
      • 1 ALS ambulance per 400,000 – 450,000 inhabitants
      • “These proportional parameters have been questioned and the SAMU coordinators negotiate their needs accordingly” (O’Dwyer)

History

  • 1980s – Emergency care provided by Military Fire Department (CBM) utilizing Anglo-American model
    • “US model of ambulance medical care began to be used by the Military Fire Department (CBM) in the late 1980s, with such professionals working as emergency medical technicians and providing care for traumas. The state of Rio de Janeiro was pioneer in this mode of care and has remained a benchmark by virtue of other emergency care initiatives it has developed” (O’Dwyer)
  • SAMU Serviço de Atendimento Móvel de Urgência (Mobile Emergency Care Service)
    • Three main stages of emergency care development (Machado)
      • 1998-2003: Federal regulation
        • “Produced the rules and defined the resources for the regulation of care services essential for tackling morbidity and mortality indicators” (O’Dwyer)
        • 2000 – Report to Congress describes lack of regulation:
          • “The Health Care Secretary (…) stood at the opening of congress and said that there actually was no medical emergency policy established in the Ministry and that he was open to hold discussions (…) we worked enthusiastically through congress to make a report and a national proposal to be submitted to the Ministry (O’Dwyer)
          • “Communities of specialists (health professional networks and councils) pieced together alternatives for emergency medical service and were able to exert influence on the Ministry of Health in the early 2000s, resulting in the first regulatory standards being established for the field” (Machado)
      • 2004-2008 – Major expansion of SAMU services
        • “In Rio de Janeiro, pioneer state in pre-hospital care provided by the Fire Department, the first regionalized SAMU of Brazil, named Metropolitan II, was installed in 2004 to service 7 municipalities and almost 2 million people.” (O’Dwyer)
      • 2009-Present: Implementation of stationary Emergency Care Units (UPA)
        • “A proposal currently exists to expand the SAMU to cover 100% of the population by 2018.” (O’Dwyer)
      • High degree of variation in the transition process from FD-based EMS to SAMU-192 strategy (O’Dwyer 2013)
      • 24hr/day, any location
        • Staffed by Physicians, Nurses, Nursing Assistants and Rescuers
      • 70 SAMU services established/operating in Brazil (Timerman, 357)
        • 320 towns in 22 states

Financing

  • Federal government-funded universal medical care: Sistema Único de Saúde (SUS) entitles population to public medical assistance – (since 1998)
    • 24.4% of population pays for full private medical assistance (Timerman, 357)

Response Agencies

  • Lead Agency: Ministry of Health
    • Makes and enforces policies guiding SAMU services
    • Hopes to establish SAMU in all Brazilian towns “respecting the jurisdiction of three administrative spheres (federal, state and municipal government)” (Timerman, 357)
    • 2006 – expected SAMU service in 1215 towns, serving population of 97m
  • Other agencies
    • General Coordination of Emergency Services (CGUE)
    • National Emergency Service Steering Committee
    • Brazilian Cooperative Network for Emergencies (RBCE)
  • Regional Agencies
    • SAMU Serviço de Atendimento Móvel de Urgência (Mobile Emergency Care Service)
      • Major provider of EMS in Brazil
    • Mobile (private) Hospital Services
      • Scarce, but more prominent in urban centers
    • Fire Department
      • When EMS is not directly available
      • BLS only, online medical direction
  • Rio de Janeiro
    • 1986-1998: run by Military Fire Department of Rio de Janeiro State (CBMERJ)
    • SAMU is now coordinated by State
      • 3 separate SAMU agencies implemented by 2009
    • State of Rio de Janeiro has 2 of the 3 largest SAMU fleets in Brazil
  • Porto Alegre (Southern Brazil)
    • SAMU (& Fire Department)
    • Privatized Highway Services
      • Service funded by road tolls; Pt’s not charged directly
      • BLS ambulances placed 30km apart on private roads
      • ALS ambulances “staffed by relatively well-compensated physicians ($25 to $30 perhour)” (Tannebaum, 225)
    • Fully Privatized (non-highway) Services
      • Monthly insurance premium (approx. $10-15/month)
      • Uninsured can access at rate of $100-150/transport
      • MDs are “usually moonlighting residents or other physicians with no training in emergency care” (Tannebaum, 226)
    • High prevalence of ED arrivals by private transport (e.g, Taxi or bystander)

Education and Training

  • Basic team consists of a driver and a nurse technician capable of providing basic life support and using an automated external defibrillator (AED).
  • Advanced team consists of a driver, a nurse and a physician trained in advanced life support.
  • Rapid support team consists of a driver, a physician and advanced support equipment to complement the basic unit team 

Medical Direction

  • Regulation Center
    • Communication Operators take calls (acting as medical regulation assistants)
    • Identifies nature of emergency and immediately transfer call to dispatching physician
    • Physician determines appropriate resource response
      • Can refer caller to public health center
      • Mobilize BLS and/or ICU-ALS ambulance
    • Physician in communication with public hospital and keeps track of bed availability
OVERVIEW
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Emergency Dispatch
  • 192 – common single access number, toll-free
    • Not universal (Bloem, 9)
Clinical Emergency Medicine
  • Emergency Medicine not yet recognized as stand-alone specialty
    • Considered sub-division of internal medicine
  • 2002 – MOH issued “Portaria 2048” which outlined way for entire healthcare system to improve emergency care due to increasing injury victims and overcrowding of EDs (Bloem, 9)
  • 50% of medical school graduates do not get residency positions (Bloem, 9)
    • “These new physicians with minimal clinical training look for work in emergency departments”
  • 2008 – 2 existing Emergency Medicine residency training programs (based on American model) – (Bloem, 10)
    • Porto Alegre
    • Fortaleza, Ceará
    • Other programs in planning
  • Emergency hospital units (Timerman, 358)
    • Type I – located in small general hospitals
      • “First-level of care of only minor complexity”
    • Type II – located in medium-sized hospitals
      • “Able to provide emergency care of medium complexity”
    • Emergency Reference Hospital Units
      • “Able to provide emergency care at high levels of complexity”
      • Funded on basis of numbers and complexity of patients.
Disaster Response
  • Expand general coverage of SAMU
  • Decrease response times between call and on-scene arrival
  • Recognize Emergency Medicine as stand-alone specialty
  • Make available/increase emergency courses for Physicians, Nurses and Health Technicians (e.g., BLS, ACLS, ATLS, PALS)
  • Provide widespread public access to defib education/programs
References
  • https://www.cia.gov/library/publications/the-world-factbook/geos/br.html
  • Bloem C: “Emergency Medicine in Brazil.” American Academy of Emergency Medicine 2008;15(6):9-11.
  • Machado CV, Salvador FGF, O’Dwyer G: Mobile Emergency Care Service: analysis of Brazilian policy (O Serviço de Atendimento Móvel de Urgência no Brasil: uma análise da política nacional). Revista de Saúde Pública 2011;45(3):519–528.
  • Nielsen K, Mock C, Joshipura M, Rubiano AM, Zakariah A, Rivara F. Assessment of the Status of Prehospital Care in 13 Low- and Middle-Income Countries. Prehosp Emerg Care. 2012:10;16(3):381–9.
  • O’Dwyer G, Mattos RA: The SAMU, the regulation in the State of Rio de Janeiro and integral care according to managers of the three government levels (O SAMU, a regulação no estado do Rio de Janeiro e a integralidade segundo gestores dos três níveis de governo). Physis 2012, 22(1):141–160.
  • O’Dwyer G, Konder MT, Machado CV, Alves CP, Alves RP. The current scenario of emergency care policies in Brazil.BMC Health Serv Res. 2013;13(1):70.
  • Semensato G, Zimerman L, Rohde LE. Initial evaluation of the Mobile Emergency Medical Services in the city of Porto Alegre, Brazil. Arq. Bras. Cardiol. 2011;96(3):196–204.
  • Tannebaum RD, Arnold JL, De Negri Filho A, Spadoni VS: “Emergency Medicine in Southern Brazil.” Annals of Emergency Medicine 2001;37(2):223-8.
  • Timerman S, Gonzalez MMC, Zaroni AC, Ramires JAF: “Emergency medical services: Brazil.” Resuscitation 2006;70:356-9.
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