The report published in 2015 by the Lancet Commission on Global Surgery ¹1. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015; 386:569-624. considers the provision of surgical care an essential component of health systems and a major public health problem. The report defends the inclusion of access to surgical care on the health agenda, based on the principles of universal coverage, equity, and justice. Six indicators were selected, along with a structure for drafting a national plan to assess the current situation: access to timely essential surgery; specialist surgical workforce density; surgical volume; peri-operative mortality rate; risk of impoverishing expenditure; and risk of catastrophic expenditure.

The application of these indicators in Brazil identified huge geographic inequality and regional differences in the supply of surgical care and the availability of qualified professionals, namely surgeons and anesthetists. Brazil’s hospital network is considered inefficient, with 57% of hospitals having 50 or fewer beds and 35.72% of hospitals concentrated in the Southeast region ²2. Brito LAL, Malik AM, Brito E, Bulgacov S, Andreassi T. Management practices in medium-sized private hospitals in São Paulo, Brazil. Cad Saúde Pública 2017; 33:e00030715.. The population in remote locations has to travel large distances to access a hospital that provides timely and effective care, including in emergency situations. Meanwhile, the number of beds in a hospital influences the quality of care provided, particularly surgical care, with a higher risk of adverse surgical events in small hospitals ³3. Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Murillo J, Ruiz-López P, Limón-Ramírez R, Terol-Garcia E, et al. Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events. J Epidemiol Community Health 2008; 62:1022-9.. Studies suggest an inverse relationship between volume of high-risk surgical procedures and mortality ⁴4. Kitazawa T, Matsumoto K, Fujita S, Yoshida A, Iida S, Nishizawa H, et al. Perioperative patient safety indicators and hospital surgical volumes. BMC Res Notes 2014, 7:117.. The authors also emphasized the performance of simultaneous procedures by surgeons and anesthetists or by untrained professionals. Such practice definitely leads to negative results in the quality of surgical care and patient safety.

The peculiarities of the Brazilian Unified National Health System (SUS) and the country’s large territory affect the supply of low, medium, and high-complexity surgical procedures. As highlighted by the authors, planning for increases in the coverage of low and medium-complexity surgeries should consider outpatient surgeries. Outpatient surgical centers should be designed to perform low and medium- complexity procedures in patients with good clinical status and who do not require staying more than 12 hours in the health service, leading to a reduction in operating costs. Adverse events, including deaths, raise concerns over patient safety and the need for government regulation. Quality improvement efforts in outpatient surgical care should seek adherence by surgeons and anesthetists to Brazilian Federal Board of Medicine (CFM) Resolution 1,886/2008⁵5. Conselho Federal de Medicina. Resolução CFM nº 1.886/2008. Diário Oficial da União 2008; 21 nov., which sets minimum standards for functioning of medical offices and surgical centers for short-stay procedures. To guarantee that the patient can recover and be discharged within a reasonable time frame, standards and general criteria for patient selection need to be followed, regardless of where the outpatient care is located, with special attention to the presence of high-risk medical conditions, besides assessing the nature of the procedure and the adequacy for outpatient care, considering the procedure’s duration and complexity ⁶6. Shapiro FE, Punwani N, Rosenberg NM, Valedon A, Twersky R, Urman RD. Office-based anesthesia: safety and outcomes. Anesth Analg 2014; 119:276-85.. Another potential strategy for increasing the coverage of surgical procedures is mobile surgical units, equipped and staffed to offer routine clinical and surgical care ⁷7. Marom T, Dagan D, Weiser G, Mendlovic J, Levy G, Shpriz M, et al. Pediatric otolaryngology in a field hospital in the Philippines. Int J Pediatr Otorhinolaryngol 2014; 78:807-11..

The 55th World Health Assembly in 2002 recommended greater attention to patient safety issues by the World Health Organization (WHO). Acknowledging the increased risk faced by surgical patients, the WHO published guidelines to improve safety in surgical care, organized as a campaign, Safe Surgery Saves Lives, based on safe surgical practices focused on the prevention of surgical site infections, safe anesthesia, better peri-operative communication, and the use of surgical care indicators ⁸8. Organização Mundial da Saúde. Segundo desafio global para a segurança do paciente: cirurgias seguras salvam vidas (orientações para cirurgia segura da OMS). Rio de Janeiro: Organização Pan-Americana da Saúde/Ministério da Saúde/Agência Nacional de Vigilância Sanitária; 2009..

The Surgical Safety Checklist (SSC) is designed as a simple and brief tool whose main objective is to ensure that teams consistently follow critical safety steps, aimed at minimizing the most common and avoidable risks that compromise the surgical patient’s life and well-being ⁸8. Organização Mundial da Saúde. Segundo desafio global para a segurança do paciente: cirurgias seguras salvam vidas (orientações para cirurgia segura da OMS). Rio de Janeiro: Organização Pan-Americana da Saúde/Ministério da Saúde/Agência Nacional de Vigilância Sanitária; 2009.. Items were included on the basis of clinical evidence or the opinion of experts on the reduction of odds of avoidable and serious surgical harms. The Brazilian Ministry of Health published the Safe Surgery Protocol as part of the National Patient Safety Program, based on the WHO guidelines, with the aim of reducing surgical incidents and mortality ⁹9. Ministério da Saúde. Portaria nº 1.377, de 9 de julho de 2013. Diário Oficial da União 2013; 10 jul..

Validation of the SSC as an effective barrier to adverse events resulting from surgery and anesthesia was based on a multicenter international study by Haynes et al. ¹⁰10. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360:491-9.. Surgical complications, an important cause of death and disability worldwide, are devastating for patients, families, and society, expensive for health systems, and often avoidable. Their prevention requires changes in the process of surgical care and the individual behavior of the professionals involved ⁹9. Ministério da Saúde. Portaria nº 1.377, de 9 de julho de 2013. Diário Oficial da União 2013; 10 jul.. The SSC significantly reduces adverse events, and its widespread implementation and effective use can avoid a large number of deaths and disabling complications, bringing unequivocal benefits for patients ¹¹11. Howell AM, Panesar SS, Burns EM, Donaldson LJ, Darzi A. Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery. Ann Surg 2014; 259:630-41..

The managers of SUS at the three levels of government have a fundamental role in drafting public policies and planning actions to reduce regional and local inequalities, dealing with the problems identified, and setting priorities, always in light of adherence to best practices.

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