7 August 2020 Health infrastructure standards: lessons learned during the COVID-19 pandemic
by Thiago Mendonça de Souza Almeida
The world continues to experience the scenario imposed by the pandemic of COVID-19 with distinct moments of confrontation, once the “ground zero” of contamination took place and as it continues to happen at different times in the different quadrants of the planet. This scenario repeats itself in Brazil due to its continental territorial extension, as well as the implementation of various strategies by health managements to face it. Among these, some stand out, such as those directed to health infrastructure, those related to regulations, assistance flows or the solutions for the rapid implantation of Estabelecimentos Assistenciais de Saúde (Health Assistance Establishments) – EAS, aiming to mitigate problems in a health system already compressed in the routine. The moment still persists, but there is already a systemic view of the post-pandemic in relation to what can and what should be improved with the teachings experienced in this scenario, including the norms related to health infrastructure in the country.
The Ministry of Health declared, through Ordinance GM/MS No. 188, of February 3, 2020, Public Health Emergency of National Importance (ESPIN) due to Human Infection with the new Coronavirus (SARS-CoV-2). Since then, what has been seen is the exponential increase in cases occurring heterogeneously across the country.
Various strategies have been adopted by the three governmental spheres, and also by other actors in society, to mitigate the effects of the pandemic. It can be said that the actions related to the restructuring and expansion of health infrastructure in the country are listed among the most important ones at this time. Giving the minimum conditions to the stage so that the real actors of health – doctors, nurses, technicians, physiotherapists, and other professionals and workers in the sector – are able to act, is the minimum expected to provide patient safety. However, it is not an easy task when the stage is already in deplorable conditions, and that is what the current scenario has “widely opened”. The health system, especially the public one, routinely experiences an eternal contingency, and today it lives a “contingency within contingency”. Among the various strategies adopted in relation to the theme, some deserve mention.
Hospitalization was one of the most important hospital functional units to deal with the pandemic. Thus, there was a need to expand beds in the health care network, the result of which was the dissemination of temporary itinerant units called “field hospitals”, which have their program aimed at “part” of the hospital, this part being precisely the hospitalization. It is worth mentioning that this functional unit, hospitalization, in the routine has never functioned autonomously, due to the direct relationship with other hospital sectors. However, due to the multiplication of these units around the world, at the end of March 2020 the World Health Organization (WHO) launched a guidance manual on the topic, the Severe Acute Respiratory Infections Treatment Center, available at the following email address: https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre.
Figure 1 – Guidance manual – Treatment center SARG. Source: OMS.
In Brazil, such campaign units were admitted to operate autonomously and temporarily (while the pandemic scenario lasts), including being registered in the National Registry of Health Establishments (CNES) of the Ministry of Health. The management of the Unified Health System – SUS must follow infrastructure criteria, cited by Technical Note (NT no. 141/2020) of the National Health Surveillance Agency (ANVISA), and also obeying the specific Ordinance of the Ministry of Health (PT GM MS no. 1.514 / 2020), which defines criteria with a systemic view of the implantation of such units in the health care network and directing to a guidance manual for the implantation of such units, available at: https://portalarquivos.saude.gov.br/images/pdf/2020/July/06/APRESENTA—-O-HOSPITAIS-CAMPANHA-MS.pdf
Figure 2 – Suggested flow in the network (field hospitals). Source: Ministry of Health.
Despite the institutional efforts of the Federal Government to regulate this possibility, what was observed was the launch of this strategy by health administrations at inopportune moments.
What was found in many cases was that these units failed to fulfill the function of being a complementary strategy in the supply of beds in the network, becoming competitors with the other existing and permanent units, in relation to the inputs, equipment, and professional team. Since these units have high implantation values, resolution with technical assistance limitations and temporary character that leaves no legacy in the health care network, it is ideal to prioritize investments and adjustments in the existing structure.
The need to quickly install units proved the obvious: the current health norm in the country, RDC no. 50/2002 ANVISA does not include in its text a quote with a methodological structure that encompasses such mobile units (hence the need to launch a Technical Note mentioned above), it does not rule on mobile health units, as the agency insists during the revision of the health norm.
Figure 3 – Card, norm review RDC 50/2002. Source: ANVISA
Both in the itinerant and temporary units created and in the permanent and existing units, the structural problems were explicit, the “installations of air conditioning systems” currently taking the leading role, where many sectors of different health establishments need systems that provide the air renewal, High Efficiency Particulate Arrestance – HEPA filtration and positive or negative pressure, items considered as a true “utopia” for the reality of SUS units.
Another great lesson that needs to be learned within this scenario is the “confusion of concepts”, sometimes related to the function, sometimes related to the degree of technical resolution of the EAS. An example was the indiscriminate speech about the existence of beds in the Intensive Care Unit (ICU) in field hospitals or in Emergency Care Units – UPA 24 hours. Of course, in a situation of chaos, it is necessary to find a direction to take, but it is also necessary that the direction taken really leads to a resolute and coherent path. All the technology can be implanted in order to create an ICU bed with dimensions and systems such as medical gases, electrical (supply and emergency) and the IT-Medical system, consistent with the ICU beds of existing and permanent hospitals. Even so, it is difficult to have an ICU sector with all the systemic needs implanted in such units, mainly due to the fact that this patient needs access to services which are not offered at the bedside at any time, but in adjacent sectors such as a surgical center (for example). Aside from the most important, a multidisciplinary, trained, and integrated professional team, which is responsible for a dozen lines of care and needs to be ready to act. Thus, to affirm the existence of such a functional unit (ICU) is to affirm that any patient in the network (critical) can be admitted so that a diagnosis and therapy are made possible, all for a long stay – this is to admit, for example, a high-risk pregnant woman with COVID-19, which could bring serious risks to this profile of patient.
Concern for this point does not refer to compliance with the cold ruling of health norms, but rather to the principle of reasonability related to the patient’s own safety, as Dr. Welfane Cordeiro (Sírio-Libanês hospital) quotes, “these field units serve only to protect the permanent hospital of medium and high complexity, the latter is the one which is truly able to treat the critical patient ”.
Another strategy, launched by the Ministry of Health to increase the possibility of access by the population to hospitalization, with a progressive look at health care, was the creation of beds of Pulmonary Ventilatory Support (LSVP), which is characterized by the level of resolvability between the bed clinic and the ICU bed, regarding space, staff, and supplies (the three S’s), aligned with a technical speech with ANVISA, which defined its infrastructure characteristics. This strategy refers to the intermediate care beds that exist mainly in the supplementary network and that for many years have not had definitions in relation to their characteristics.
This moment will pass, and when it happens, that the spotlight turned during the pandemic to the deficiencies of the much needed (and, at the same time, compressed) health network infrastructure in the country, especially that of SUS, is not erased. To that end, normative acts that induce the restructuring of the network in a responsible manner need to be created or revised.
A good example is the application of the “Safe Hospitals” program, where Brazil signed a commitment with the Pan American Health Organization (PAHO) in 2010 to create guidance manuals on the topic, but so far little has been done. Perhaps including such a premise as a necessary tool to enable and qualify new health units within the assistance policies of the Ministry of Health.
It will also be crucial to review the proposal of the RDC standard no. 50/2002 ANVISA (which has just come out of the public consultation process), since it was clear that its scope deals with permanent and existing health units in the network and not traveling and temporary units, thus creating a standard of good practice for mobile and other temporary units such as field hospitals, putting an end to the historic regulatory vacancy on these units. This could resolve a possible distortion in the review of such an important normative act, which has not even been completed. Now for the text of the current norm put under review, even with its focus turned to the evaluation of the consultants of the Health Surveillance (VISA), one cannot forget the other actors that use it, including the designer, once their title quotes “ planning, programming, elaboration ”. Therefore, one truly needs to look at issues related to the quality of indoor environments, which is related for example to hygrothermal comfort. Otherwise, that the responsible agencies create complementary guidance manuals and make them available to society, such as the updating of the Support System for the Development of Health Investment Projects (SOMASUS) of the Ministry of Health, since a series of rules of the Brazilian Association Technical Standards (ABNT) is not open to public access.
On the same topic and in a complementary manner, it will also be of paramount importance to re-establish the National Biosafety Council (created in 2002), in order to reactivate the discussion on a ruling that will deal with a classification of the health risk for EAS.
The Medical-Sanitary Census of the Brazilian Institute of Geography and Statistics (IBGE), which was last updated in 2009, has been reactivated and is still being updated. This is yet another document that can and should contribute to a diagnosis of the real situation of hospital and non-hospital units in the country and should be completed as soon as possible.
Furthermore, betting on maintaining and improving the standardization of inclusion of Lung Ventilatory Support beds, perhaps migrating and adapting its concept (making it more generic) in the post-pandemic, so that it assumes its real and permanent function in the health network: the intermediate care bed, which has the “3 S’s distinct from both the clinical ward bed and the ICU bed. The maintenance of the intermediate care bed would fill in the gaps with the insertion in the inpatient units assuming the role of semi-intensive bed, and in the Emergency Care Units (PA) assuming the function of an urgency bed, since nowadays we only have beds for emergency rooms, contributing to the structuring of an adequate space for the patient who is in a clinical situation between the moderate and the critical.
Another line of action is to take advantage of the legacy of the assertive guidance studies launched by the technical team of the Brazilian Hospital Services Company (EBSERH) in their manuals, which aim to take advantage of and reuse “what exists” in the network of their hospitals, and also the flows developed by teams from the Ministry of Health, both those involving clinical management and those directed to infrastructure.
Figure 4 – New Technic no. 6/2020 EBSERH. Source: EBSERH
Maybe it is to dream big to see a norm published, as we have the performance standard for residential buildings – ABNT NBR 15575: 2013, in a version aimed at health units.
Anyway, there is much to be done, and as the present text cites, there is no lack of paths to be taken. That the normative acts are adapted to the so-called “new normal”, and that those responsible for the updates have even more empathy for patients and health professionals. For the specific case provided by the pandemic that continues to affect the world, that the government may constitute a complementary instrument to the emergency decree, being able to make an outline in the concurrent principle of health regulations in the country (mentioned in our Constitution), so that, in a state of calamity, it can act fully in directing the main commands, thus “turning the key” from routine medicine to the medicine of mass victims, as it is already the case in most European countries.
Ministry of Health. https://coronavirus.saude.gov.br/profissional-gestor#publitecnicas
National Health Surveillance Agency. http://portal.anvisa.gov.br/coronavirus
Empresa Brasileira de Hospitais. https://www.gov.br/ebserh/pt-br
World Health Organization. https://www.who.int/emergencies/diseases/novel-coronavirus-2019
Pan American Health Organization. https://www.paho.org/bra/index.php?option=com_content&view=article&id=1232:reuniao-discute-hospitais-seguros-e-ajuda-humanitaria-internacional&Itemid=839