Abstract

The Urgent and Emergency Care Network (RUE) was proposed in Brazil as a public policy to articulate and integrate the health services of the Brazilian National Health System (SUS), expanding and qualifying the access of users in e emergency health situations in an efficient and timely manner. This study analyzes the scientific production on the RUE in Brazil and elaborates summaries showing the limits and challenges of this health policy. An integrative literature review was used as a method, based on the search for articles in the LILACS, SciELO, and MEDLINE databases and for dissertations and theses on the virtual platform of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). The investigation enabled the analysis of 34 studies in the field of collective health, focused on the different emergency services and the integration between them, including possible changes in the health care process and different evaluation strategies, by using different approaches, mainly qualitative. Weaknesses are observed in the network articulation, maintaining the centrality of hospital services and the power of its symbolic capital, with primary care being relegated to the discursive field.

Keywords:
Health Care; Health Services; Emergency; Health Policy

Introduction

The organization of the Brazilian Unified Health System (SUS) started, in 2010, to use the Health Care Networks (Redes de Atenção à Saúde - RAS) as its model. This proposal was recommended by the Pan American Health Organization (PAHO), based on the framework of the Integrated Health Services Networks (Redes Integradas de Serviços de Saúde - RISS), and it has been implemented as an alternative to the fragmentation of health systems (PAHO, 2010OPAS - ORGANIZAÇÃO PAN-AMERICANA DA SAÚDE. Redes integradas de servicios de salud: conceptos, opciones de política y hoja de ruta para su implementación en las Américas. Washington, DC, 2010.), especially in countries in the process of demographic and epidemiological transition where chronic conditions and injuries are prevalent (Mendes, 2010MENDES, E. V. As redes de atenção à saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 15, n. 5, p. 2297-2305, 2010. DOI: 10.1590/S1413-81232010000500005
https://doi.org/10.1590/S1413-8123201000... ). Established as a public policy in the country, the RAS is defined as a polyarchic system model consisting of different points of health care and the links that communicate them, with the objective of obtaining better epidemiological and comprehensive results of health care (Brasil, 2017BRASIL. Ministério da Saúde. Portaria de Consolidação nº 3, de 28 de setembro de 2017. Consolidação das normas sobre as redes do Sistema Único de Saúde. Brasília, DF, 2017.).

Thus, the induction made by the Ministry of Health to implement the RAS as a public policy represented a new phase for the structuring of the SUS. The objectives expressed in the policy included the guarantee of integrality and the performance of changes to health care provision using thematic networks of priority, such as the “Stork Network” Program (Rede Cegonha), Emergency Care Network (Rede de Atenção às Urgências e Emergências - RUE), Psychosocial Care Network (Rede de Atenção Psicossocial), Care Network for People with Disability (Rede de Atenção à Pessoa com Deficiência), and Care Network for People with Chronic Diseases (Rede de Atenção às Doenças Crônicas) (Brasil, 2014BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Implantação das Redes de Atenção à Saúde e outras estratégias da SAS. Brasília, DF, 2014.).

The RUE was proposed to articulate and integrate health facilities, aiming to expand and qualify the access of users to urgent and emergency health care in an efficient and timely manner. Their components are defined as: health promotion, prevention, and surveillance; Primary Health Care; Mobile Emergency Care Service (SAMU 192) and its Emergency Medical Care Regulation Centers (Centrais de Regulação Médica das Urgências); stabilization rooms; National Health Force of the SUS; Emergency Care Units (UPA 24h) and all its 24-hour emergency services; Hospitals; and Home Care (Brasil, 2011BRASIL. Ministério da Saúde. Portaria nº 1.600, de 7 de julho de 2011. Reformula a Política Nacional de Atenção às Urgências e institui a Rede de Atenção às Urgências no Sistema Único de Saúde (SUS). Diário Oficial da União, Brasília, DF, 8 jul. 2011. Seção 1, p. 69-70.). In recent years, advances have been made in the implementation of RUE, with some relevant results. Nevertheless, there is much to be improved, and a series of difficulties need to be overcome to create new management and governance arrangements for networks and new care practices that may lead to a new institutional culture in health (Jorge et al., 2014JORGE, A. O. et al. Entendendo os desafios para a implementação da Rede de Atenção às Urgências e Emergências no Brasil: uma análise crítica. Divulgação em Saúde para Debate, Rio de Janeiro, n. 52, p. 125-145, 2014.).

Considering the relevance of RUE policy, there is need for studies that seek to organize, synthesize, and disseminate research on the subject, enabling new investigations to be subsidized and motivated, promoting more visibility to scientific production on RUE, and supporting the processes of formulation, implementation, and evaluation of SUS health policies. This study aims to analyze the scientific production on RUE policy in Brazil and to elaborate summaries about its limits and challenges.

Methodology

This is an integrative review of the literature and part of a documentary analysis related to the production of knowledge on RUE’s public policy. The integrative literature review is a method composed of six phases, strictly followed in the development of this research: (1) establishment of the central problem of the review and elaboration of the main driving question; (2) selection of studies; (3) categorization of studies and definition of information to be extracted from the reviewed studies; (4) analysis of the selected material; (5) interpretation of the results; and (6) synthesis of the attested knowledge (Mendes; Scott; Galvão, 2008MENDES, K. D. S.; SILVEIRA, R. C. de C. P.; GALVÃO, C. M. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & Contexto - Enfermagem , Florianópolis, v. 17, n. 4, p. 758-764, 2008. DOI: 10.1590/S0104-07072008000400018
https://doi.org/10.1590/S0104-0707200800... ).

For the preparation of this literature review, the central question of the research was initially defined: what did the studies find regarding RUE since its implementation?

To identify the studies to comprise the review, an online search of articles was performed in the LILACS, SCiELO, and MEDLINE databases. Dissertations and theses were also researched in the virtual platform of the Coordination for the Improvement of Higher Education Personnel (CAPES) of the Ministry of Education. The Descriptors of Health Sciences (DeCS) “Redes de Urgência e Emergência” (Urgent and Emergency Networks) and “Redes + Serviços de Urgência” (Networks + Emergency Services) were used.

The universe of the study consists of 16 scientific articles, 18 master’s theses, and 6 PhD dissertations related to the investigated theme; of these, 34 constitutes the sample. The study selection process (Figure 1) was carried out in three stages: (1) elimination of duplicates; (2) reading of titles and abstracts; and (3) reading the texts in full. The following inclusion criteria were considered: publications available in full, published or produced from 2011 to 2020 as scientific article, dissertation, or thesis. Exclusion criteria were duplicity and studies that do not directly address the subject of RUE.

From the reading of the studies, the different components of the RUE were categorized to perform the analysis of the results and discussion. In order to systematize data collection, a matrix was elaborated, and the results were organized in tables for better visualization of the material included in the research.

Results and discussion

The research enabled the analysis of 34 studies in the field of collective health on the subject of RUE. Nine studies addressed general aspects of RUE. Among the components addressed, most studies were on hospitals (11 studies), UPA 24h (8), and SAMU 192 (5). Only one research was identified for Primary Health Care and for Home Care. No studies were found on health promotion, prevention, and surveillance, on RUE’s Stabilization Room, and on the National Health Force of the SUS. Regarding the type of document, the subject was mostly discussed in master’s theses (17); while 6 PhD dissertation, and 11 articles published in scientific journals were also identified. Regarding the type of study, we identified 9 evaluative studies, 6 case studies, and 13 investigations with diverse qualitative approaches, including documentary analysis, cartography, action research, and intervention project, among others. We also identified 4 studies with mixed approach (quali-quantitative) and 2 studies that were developed with quantitative methods.

The approaches of the studies on the RUE are presented below and discussed by component, according to the defined categorization.

The Emergency Care Network policy

Nine studies were identified, including articles, theses, and dissertations, with a general approach to RUE, as described in Chart 1.

Jorge et al. (2014JORGE, A. O. et al. Entendendo os desafios para a implementação da Rede de Atenção às Urgências e Emergências no Brasil: uma análise crítica. Divulgação em Saúde para Debate, Rio de Janeiro, n. 52, p. 125-145, 2014.), in an article published by the team responsible for formulating RUE within the Ministry of Health, carried out the evaluation of its implementation at the national level under the management and governance approach. For the authors, the critical obstacles to be faced are: the subdued role of the state health departments in coordinating the planning and implementation process of the RUE; the fragility of the regulatory component; the low capacity of federal entities in managing financial resources; insufficient monitoring and evaluation processes; the inadequacy of information systems; and the lack of permanent education plans for the implementation of clinical qualification and management devices in regional action plans.

Other studies analyze the planning and implementation of RUE according to different approaches within health regions of the states of Ceará, Minas Gerais, Paraná, Rio de Janeiro, Santa Catarina, and São Paulo, considering the different regional characteristics.

For Teixeira (2014TEIXEIRA, J. M. C. Análise do processo de implantação da Rede de Atenção às Urgências e Emergências na Região Metropolitana de Fortaleza Ampliada. 2014. 109 f. Dissertação (Mestrado em Saúde Pública) - Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, 2014.), despite the political and financial investment for the implementation of RUE, this strategy did not solve the serious problems of integration between health units in the Metropolitan Region of Fortaleza (in the state of Ceará). Moreover, the study exposed the low capacity of Primary Health Care as a care management entity, the critical difficulty in funding, and the fragility in the articulation between the management bodies of the system and the management of the services.

Some studies focused on the regional governance for the planning and implementation of RUE. Padilha et al. (2018PADILHA, A. R. S. et al. Fragilidade na governança regional durante implementação da Rede de Urgência e Emergência em Região Metropolitana. Saúde em Debate , Rio de Janeiro, v. 42, n. 118, p. 579-593, 2018. DOI: 10.1590/0103-1104201811803
https://doi.org/10.1590/0103-11042018118... ) revealed the insufficiency of the political instruments and coordination arrangements developed by the implementation of RUE in the Metropolitan Region of São Paulo. For Costa (2015COSTA, M. G. L. da. Análise da governança na saúde: Rede de Atenção às Urgências e Emergências da região do Médio Paraíba-RJ. 2015. 111 f. Dissertação (Mestrado em Saúde Coletiva) - Faculdade de Medicina, Universidade Federal Fluminense, Niterói, 2015.), the inter-management spaces of the State’s RUE Management Group and the Regional Interagency Committee (CIR) in the Middle Paraíba Region performs far below of what was proposed, needing to advance in the culture of elaboration of regional projects that can truly consider local specificities.

In the Western Health Region of Paraná, Griep (2018GRIEP, R. A construção e governança da Rede de Atenção às Urgências na Região Oeste do Paraná: um estudo de caso. 2018. 183 f. Tese (Doutorado em Saúde Coletiva) - Centro de Ciências da Saúde, Universidade Estadual de Londrina, Londrina, 2018.) observed that, despite the advances, CIR’s performance took place during the implementation phase of RUE, in which a normative planning with strong central induction prevailed, triggered by the edition of legal norms that promote wave reactions with the Bipartite Interagency Committee (CIB) and CIR. When conducting a case study in the Health Region in the countryside of the state of São Paulo, Pereira (2017PEREIRA, A. P. F. Rede de Urgência e Emergência: um estudo de caso na Região Coração do estado de São Paulo. 2017. 105 f. Dissertação (Mestrado em Gestão do Trabalho) - Centro de Ciências Biológicas e da Saúde, Universidade Federal de São Carlos, São Carlos, 2017.) emphasized, as some of the driving elements of RUE, the importance of systematic meetings between the representatives of the constituent facilities and the public administrators of the municipalities of the region, the creation of the regulatory forum, and the management tools that contribute to the organization of care at the entry points of health care.

In the Fortaleza Health Region, Morais (2018MORAIS, J. B. de. Análise da implantação da Rede de Atenção às Urgências e Emergências na Região de Saúde Fortaleza. 2018. 194 f. Tese (Doutorado em Saúde Coletiva) - Centro de Ciências da Saúde, Universidade Estadual do Ceará, Fortaleza, 2018.) observed that the implementation of a set of RUE components was not equally accompanied by the process of modifying the care model towards a comprehensive, resolutive, qualified, and user-centered care, especially due to the emphasis on structuring via physical resources in detriment to conditioning aspects of network functionalities. Panzera (2014)PANZERA, C. S. T. Rede de Urgência e Emergência na Grande Oeste de Santa Catarina e a Educação. 2017. 113 f. Dissertação (Mestrado em Ensino na Saúde) - Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, 2014., when conducting interviews with workers, public administrators, and users of the RUE in the Greater Western Region of Santa Catarina, identified the discontinuity, fragmentation, and fragility within the coordination of care toward users and proposed permanent health education actions that may strengthen the network.

By studying the social representation of RUE to public administrators and workers in a municipality in the state of Minas Gerais, Resende (2018RESENDE, M. A. Representações sociais de gestores e trabalhadores sobre a Rede de Atenção às Urgências. 2018. 107 f. Dissertação (Mestrado em Política, Gestão e Avaliação do Sistema Único de Saúde) - Faculdade de Medicina, Universidade Federal de Juiz de Fora, Juiz de Fora, 2018.) reported the perception that RUE guarantees an optimization of care, and, in this sense, when done in a participatory way, the professionals who are part of the process feel satisfied when they recognize themselves as participating members of the decisions.

Thus, investments in the processes of integration, regional governance, and qualification of health care are presented as requirements for its effective implementation in the RUE and the guarantee of its objectives.

Primary and Home Care in the Emergency Care Network

The Primary Care component in RUE aims to expand access, strengthen the bond, and be the first contacts of care in emergencies until transfer/referral to other points of care, when necessary (Brasil, 2011BRASIL. Ministério da Saúde. Portaria nº 1.600, de 7 de julho de 2011. Reformula a Política Nacional de Atenção às Urgências e institui a Rede de Atenção às Urgências no Sistema Único de Saúde (SUS). Diário Oficial da União, Brasília, DF, 8 jul. 2011. Seção 1, p. 69-70.). The Home Care component is understood as the set of integrated and articulated actions of health promotion, prevention, and treatment of diseases and rehabilitation that occur at home, constituting a new modality of health care that reorganizes the work process of teams in primary, outpatient, and hospital care (Brasil, 2011BRASIL. Ministério da Saúde. Portaria nº 1.600, de 7 de julho de 2011. Reformula a Política Nacional de Atenção às Urgências e institui a Rede de Atenção às Urgências no Sistema Único de Saúde (SUS). Diário Oficial da União, Brasília, DF, 8 jul. 2011. Seção 1, p. 69-70.).

The research found few scientific productions on these components of RUE, and only one study was identified for each of them (Chart 2).

Notably, both studies focused on the health care practices, indicating in their results and conclusions the need to further the articulation of the network. In the case of Primary Care, the author evaluated the theoretical knowledge of professionals working in the Family Health Strategy of a municipality regarding urgent and emergency conducts, showing the differences between professional categories and lines of care, indicating that training processes can minimize morbidity and mortality and contribute to the reduction of excessive demand at the entry points of other levels of care, making RUE more effective and Primary Care more resolutive (Crispim, 2016CRISPIM, S. F. Conhecimento teórico de profissionais atuantes na Estratégia de Saúde da Família sobre condutas em urgência e emergência. 2016. 107 f. Dissertação (Mestrado) -Universidade Federal de Mato Grosso do Sul, Campo Grande, 2016.).

Pozzoli (2017POZZOLI, S. M. L. Cartografia do processo de cuidado num Serviço de Atenção Domiciliar. 2017. 178 f. Tese (Doutorado em Ciências) - Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, 2017.), when studying the care process within a Home Care service, observed that it is an innovative care model if embraced by the health system with sufficient human resources, materials, equipment, transportation, and an efficient and flexible information system, suggesting for patient care to be integrated among professionals from other points of the network.

Pre-hospital care: Mobile Emergency Care Service and Emergency Care Unit

Pre-hospital care in RUE consists of two components: SAMU 192 and UPA 24h. In this research, 12 studies on pre-hospital care within RUE were identified: 4 on Mobile Emergency Care Service (SAMU 192), 7 on 24-hour Emergency Care Unit (UPA 24h), and 1 that addressed both components (Chart 3).

SAMU 192 aims to reach the victim soon after a health incident that can lead to suffering, sequelae, or even death, thus requiring adequate care and/or transportation to a health service properly hierarchical and integrated with the SUS (Brasil, 2011BRASIL. Ministério da Saúde. Portaria nº 1.600, de 7 de julho de 2011. Reformula a Política Nacional de Atenção às Urgências e institui a Rede de Atenção às Urgências no Sistema Único de Saúde (SUS). Diário Oficial da União, Brasília, DF, 8 jul. 2011. Seção 1, p. 69-70.).

In a study conducted at SAMU 192 in the city of Rio de Janeiro, Dias (2012DIAS, R. L. Regulação médica de urgências na região do Médio Paraíba: uma proposta para avaliação da implantação do serviço. 2012. 99 f. Dissertação (Mestrado em Administração em Saúde) - Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, 2012.) evaluated the performance of the Regulatory Center as an important strategy to mitigate unnecessary demands at health care entry points and also as a tool for defending citizens, ensuring their access to environments appropriate to their needs. Assis (2018ASSIS, A. C. P. Governança do componente pré-hospitalar móvel da Rede de Atenção às Urgências e Emergências (RUE) em uma Região de Saúde no estado do Paraná. 2018. 136 f. Dissertação (Mestrado em Saúde Coletiva) - Centro de Ciências da Saúde, Universidade Estadual de Londrina, Londrina, 2018.) notes that, although the SAMU 192 Regulatory Center in a Health Region of the state of Paraná meets the standardization, its operationalization does not always occur as established, presenting weaknesses and potentialities in its governance system, such as the ineffectiveness of the local and regional administrative committees; absence of a computerized system for locating available beds, transport vehicles, and system of hospital reference agreements; non-existent interinstitutional ordering with the Military Police and the Fire Department; and lack of medical professionals. As potentialities, the study points out the employment relationship of the team by means of a single legal regime with low turnover of professionals and the designation of a health authority to the regulatory physician.

Regarding identified intervention proposals, Nagai (2017NAGAI, D. K. Diretriz de integração do Samu com os componentes APS e UPA na Rede de Urgência e Emergência: pesquisa-ação. 2017. 109 f. Dissertação (Mestrado em Gerenciamento dos Serviços de Saúde e de Enfermagem) - Universidade Federal do Paraná, Curitiba, 2017.) builds guidelines for the integration of SAMU 192 with Primary Care and UPA 24h using an action research, and Luz (2017LUZ, M. A. Certificação em ACLS na Rede de Atenção Pré-Hospitalar de Urgência e Emergência - Proposta de Intervenção no Samu e UPA CIC em Curitiba. 2017. 73 f. Dissertação (Mestrado em Gestão de Tecnologia e Inovação em Saúde) - Instituto Sírio-Libanês de Ensino e Pesquisa, São Paulo, 2017.) proposes Advanced Cardiovascular Support (ACLS) certification for professionals working in SAMU 192 and UPA 24h as an intervention project, both in the city of Curitiba (state of Parana). For Nagai (2017)NAGAI, D. K. Diretriz de integração do Samu com os componentes APS e UPA na Rede de Urgência e Emergência: pesquisa-ação. 2017. 109 f. Dissertação (Mestrado em Gerenciamento dos Serviços de Saúde e de Enfermagem) - Universidade Federal do Paraná, Curitiba, 2017., one of the expectations of SAMU 192 is the integration that this service can provide to RUE, ensuring access to all levels of complexity at the most opportune time for user service. For Luz (2017)LUZ, M. A. Certificação em ACLS na Rede de Atenção Pré-Hospitalar de Urgência e Emergência - Proposta de Intervenção no Samu e UPA CIC em Curitiba. 2017. 73 f. Dissertação (Mestrado em Gestão de Tecnologia e Inovação em Saúde) - Instituto Sírio-Libanês de Ensino e Pesquisa, São Paulo, 2017., the certification of the teams in ACLS may improve the work processes in the emergency rooms where this knowledge is needed.

In a study conducted with the objective of analyzing the process of implementation of mobile pre-hospital urgency in Brazil, O’Dwyer et al. (2017)O’DWYER, G. et al. O processo de implantação do Serviço de Atendimento Móvel de Urgência no Brasil: estratégias de ação e dimensões estruturais. Cadernos de Saúde Pública, Rio de Janeiro, v. 33, n. 7, 2017. DOI: 10.1590/0102-311X00043716
https://doi.org/10.1590/0102-311X0004371... , using Giddens’ structuration theory, reported an unequal implementation of SAMU 192 between states and regions, in addition to structural problems, such as the difficulty in maintaining physicians, poorly equipped regulatory centers, and scarcity of ambulances, with the North and Northeast Regions being the most affected.

The 24-hour UPA are health facilities of intermediate complexity, between primary care services and the hospital network, part of an organized network of emergency care that should provide resolutive and qualified care to patients affected by acute clinical or surgical conditions by stabilizing the patients and performing the initial diagnostic investigation, and defining, for every cases, if a referral to hospital services of greater complexity is required or not (Brasil, 2011BRASIL. Ministério da Saúde. Portaria nº 1.600, de 7 de julho de 2011. Reformula a Política Nacional de Atenção às Urgências e institui a Rede de Atenção às Urgências no Sistema Único de Saúde (SUS). Diário Oficial da União, Brasília, DF, 8 jul. 2011. Seção 1, p. 69-70.).

Silva et al. (2012SILVA, G. S. da et al. Redes de atenção às urgências e emergências: pré-avaliação das Unidades de Pronto Atendimento (UPAs) em uma região metropolitana do Brasil. Revista Brasileira De Saúde Materno Infantil, Recife, v. 12, n. 4, p. 445-458, 2012. DOI: 10.1590/S1519-38292012000400011
https://doi.org/10.1590/S1519-3829201200... ) proposed an instrument for evaluating the 24-hour UPA of the Metropolitan Region of Recife by using a logical model and with the formulation of consensus. They structured a matrix of criteria and indicators composed of three levels of analysis: health care (emergency care and diagnostic procedures), interinstitutional integration (complementary to Primary Care, SAMU 192, diagnostic-therapeutic support units, and hospital units), and management (administrative, financial, and quality).

In the dimension of health care, Araújo (2016ARAÚJO, L. R. P. Unidade de Pronto Atendimento: o cuidado ao usuário. 2016. 87 f. Dissertação (Mestrado em Gestão da Clínica) - Universidade Federal de São Carlos, São Carlos, 2016.), when interviewing users of 24-hour UPA in the region of Araraquara (SP), observed that the participants were satisfied with the care received, but highlights that access is disorganized in health services and there is no coordination of care, which compromises the longitudinality and comprehensiveness of care. The study also reported that the participants made their own paths or therapeutic itineraries at their convenience, often facing barriers upon access, perpetuating a hegemonic doctor-centered model of health service based on “treat and street.”

Barreto et al. (2017BARRETO, M. da S. et al. Cuidado centrado na família em unidades emergenciais: percepção de enfermeiros e médicos brasileiros. Escola Anna Nery, Rio de Janeiro, v. 21, n. 2, e20170042, 2017.), when studying the perception of professionals working in two emergency units in Southern Brazil on Family-Centered Care (FCC), identified that, for Brazilian physicians and nurses working in 24-hour UPA, the FCC is still little known formally, which led to deductive and superficial perceptions about the theme. In general, the interviewees believed that the FCC was related to involving the presence of the family in the patient care space. Notably, the professionals considered it difficult to implement the FCC in the 24-hour UPA, however, some reports mention the importance of maintaining contact between patients and family members in these contexts, presenting suggestions regarding the expansion of visiting times and opportunities.

Regarding the dimension of integration with other points of attention, Konder (2013KONDER, M. T. Atenção às urgências: a integração das Unidades de Pronto Atendimento 24 horas (UPA 24h) com a rede assistencial no município do Rio de Janeiro. 2013. 108 f. Dissertação (Mestrado em Saúde Pública) - Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, 2013.) - when studying the 24-hour UPA of the municipality of Rio de Janeiro (RJ) - observed little integration between them and the other components of the RUE, despite the strong political and financial investment for the implementation and expansion of these units. The strategy failed to circumvent the serious problems of integration into the care network, and may even generate further fragmentation.

In a documentary research of national scope regarding the implementation of the 24-hour UPA, Konder and O’Dwyer (2015KONDER, M. T.; O’DWYER, G. As Unidades de Pronto-Atendimento na Política Nacional de Atenção às Urgências. Physis: revista de saúde coletiva, Rio de Janeiro, v. 25, n. 2, p. 525-545, 2015. DOI: 10.1590/S0103-73312015000200011
https://doi.org/10.1590/S0103-7331201500... ) observed that the significant support of the federation units explains their broad legitimacy as a structuring modality achieved by this policy, allowing rapid expansion and a significant allocation of resources. The UPA 24h implementation pattern was of accelerated expansion, without effective network organization, casting suspicion on being a reproduction of the traditional emergency room model. In a study conducted in a region in the city of São Paulo (state of São Paulo), which focused on the care provided by UPA 24h to users affected by conditions sensitive to primary care, Lima (2017LIMA, A. C. M. G. de. Atendimentos por condições sensíveis à Atenção Primária à Saúde em uma Unidade de Pronto-Atendimento: proposta de comunicação para coordenação do cuidado. 2017. 92 f. Dissertação (Mestrado em Cuidado em Atenção Primária em Saúde) - Escola de Enfermagem, Universidade de São Paulo, São Paulo, 2017.) identified the strategy of referencing users with chronic diseases for continuity in Primary Care as an important strategy for service integration.

Regarding management practices in the UPA 24h, Von Randown et al. (2014)VON RANDOWN, R. M. et al. Práticas gerenciais em Unidades de Pronto-Atendimento no contexto das Redes de Atenção à Saúde. Revista de Administração em Saúde, São Paulo, v. 16, n. 64, p. 79-88, 2014. identified singularities in the city of Belo Horizonte (state of Minas Gerais) that contribute to the implementation of the structured care model from the RAS. Regarding the actions performed by the public administrators of the UPA 24h, they highlight the articulation with health care networks in the micro and macro-organizational contexts, the management of people, conflicts, flow of served individuals, in addition to the planning, evaluation, and management of health services, constituting a dense and complex activity.

The structuring of pre-hospital care in RUE is invested in the possibility of reducing the overcrowding of health care entry points and the integration of the care network. Both the UPA 24h and the SAMU 192 can contribute to these results depending on the arrangements and devices of regulation and coordination of care implemented in the territories and services, since only building a new service can maintain the fragmentation of the network and the care model centered on “treat and street” without important impact on the quality and integrality of care.

The hospital component in the Emergency Care Network

The hospital component in RUE consists of emergency entry point, stepdown units, intensive care beds, imaging and laboratory diagnostic services, and priority care lines (Brasil, 2011BRASIL. Ministério da Saúde. Portaria nº 1.600, de 7 de julho de 2011. Reformula a Política Nacional de Atenção às Urgências e institui a Rede de Atenção às Urgências no Sistema Único de Saúde (SUS). Diário Oficial da União, Brasília, DF, 8 jul. 2011. Seção 1, p. 69-70.). In this review, 11 studies on the hospital component were identified (Chart 4).

When analyzing the implementation of the hospital component of RUE in the country, Oliveira (2017OLIVEIRA, D. C. Análise de implantação do componente hospitalar da Rede de Urgências e Emergências (RUE). 2017. 41 f. Dissertação (Mestrado em Gestão) - Faculdade de Medicina, Universidade de São Paulo, Ribeirão Preto, 2017.) observed that the axis of entry points reached satisfactory level (between 70.8% and 83.8%) and the axes of stepdown units and intensive care beds reached full level of implantation (>90%). It highlights that the risk levels have not been satisfactorily implemented and that some concepts and attributions need to be better presented and promoted, such as the Internal Regulatory Nucleus, the Hospital Quality Access Nucleus, and kanban. Among the factors that limit the implementation of the RUE are the difficulties of care regulation and the insufficiency of stepdown beds and long hospitalizations. It highlights as the main progresses the implementation of multi-professional care and inter-hospital communication via the Internal Regulatory Center, which contributed to the integration in the network and in the integrality of care, despite the limitations.

Marcolino (2017MARCOLINO, F. B. U. Modelo de Avaliabilidade do Componente Hospitalar da Rede de Urgência e Emergência. 2017. 75 f. Dissertação (Mestrado) - Universidade do Extremo Sul Catarinense, Criciúma, 2017.), when building an evaluative matrix based on the guidelines present in the regulations for RUE hospitals, proposed an evaluation in two dimensions: administration - management of services/governance of networks - and hospital -the care provided. As for the results, Caluza et al. (2012CALUZA, A. C. V. et al. Rede de infarto com supradesnivelamento de ST: sistematização em 205 casos diminui eventos clínicos na rede pública. Arquivos Brasileiros de Cardiologia, Rio de Janeiro, v. 99, n. 5, p. 1040-1048, 2012. DOI: 10.1590/S0066-782X2012005000100
https://doi.org/10.1590/S0066-782X201200... ), in a study that evaluated the line of care of acute myocardial infarction in a reference hospital in the city of São Paulo (state of São Paulo), observed that the organization of public establishments in a care network resulted in immediate improvement of the results, reducing mortality rates.

Regarding hospital access within RUE, Dubeux (2012DUBEUX, L. S. A regionalização da assistência às urgências e emergências em hospitais de referência regional de Pernambuco: uma avaliação sobre a vertente do acesso aos serviços de saúde. 2012. 110 f. Tese (Doutorado em Saúde Pública) - Centro de Pesquisas Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, 2012.), when studying the regional reference hospitals in Pernambuco, observed the inadequacy of the supply and implementation in the face of the state regional model and the guidelines regarding the care necessary for urgent and emergency cases. Despite the fragility observed, most users use the hospital as a main health service, demonstrating confidence in the care received.

Soares, Scherer, and O’Dwyer (2015SOARES, E. P.; SCHERER, M. D. dos A.; O’DWYER, G. Inserção de um hospital de grande porte na Rede de Urgências e Emergências da região Centro-Oeste. Saúde em Debate , Rio de Janeiro, v. 39, n. 106, p. 616-626, 2015. DOI: 10.1590/0103-110420151060003004
https://doi.org/10.1590/0103-11042015106... ), when studying a teaching hospital of regional reference and large size in the Midwest region of the country, observed that their insertion within the RUE happened slowly, depending on the articulation of the various levels of management of the SUS, and that the definition of agreements and care flows is still incipient: there are problems in the functioning of other health services, which, in general, do not promote the selection of clinically less severe cases; access regulation is in its initial phase; Primary Health Care in the region is little resolutive; public administrators are active in the network deployment process; the workers have a little agency in the implementation of the RUE; and there is little investment in continuing health education.

The small hospitals, according to Souza (2019SOUZA, F. E. A. Hospitais em municípios de pequeno porte: sua inserção no SUS. 2019. 145 f. Tese (Doutorado em Saúde Coletiva) - Centro de Ciências da Saúde, Universidade Estadual de Londrina, Londrina, 2019.), perform below the recommended in health care for the population to which they are intended, as well as incipient insertion in the RUE. Even so, the symbolic and political capital invested in the idea of a hospital helps to understand why, even with low productivity and high costs, political agents do not “give up” on funding, expanding, and maintaining them with the means at their disposal.

As for the strategies and arrangements of hospital management recommended by the policy, Konder (2018KONDER, M. T. Regulação assistencial e atenção hospitalar na Rede de Atenção às Urgências e Emergências. 2018. 224 f. Tese (Doutorado em Saúde Pública) - Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, 2018.) highlights the fundamental role played by regulatory centers, internal regulatory centers, and medical professionals for consolidation and quality of the regulatory process in the state of Rio de Janeiro. They observes as a phenomenon an institutionalization of regulation, capable of promoting greater integration of the network, especially in the municipal sphere. However, the difficult access to an insufficient and low-skilled stepdown hospital ward, which culminates in the phenomenon of “hospitalization” in the UPA 24h, and the conflicting dynamics of relations between the governmental spheres, which maintains a segmented governance of the network, persist as obstacles to a more efficient organization of the RUE.

When analyzing the implementation of the Kanban instrument in seven hospitals participating in the SOS Emergencies program, Petry (2016PETRY, D. Análise de implantação do Kanban em hospitais do programa SOS Emergências. 2016. 151 f. Dissertação (Mestrado em Gestão de Sistemas de Saúde) - Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, 2016.) observed the actions of the Internal Regulatory Center, the Hospital Access and Quality Center, the floor team, and the hospital management as contextual factors that contributed to its implementation, in addition to the performance of the program’s supporters. The main factors that impaired its implementation include the low interest of hospital management, the lack of personnel in Kanban’s driving teams, the fluctuating and/or under-skilled teams, manual control systems, the lack of understanding of the tool, in addition to the resistance of physicians and other professionals.

On the participation of workers in the implementation process of RUE, Lima, Leite, and Caldeira (2015LIMA, D. P.; LEITE, M. T. de S.; CALDEIRA, A. P. Redes de Atenção à Saúde: a percepção dos médicos trabalhando em serviços de urgência. Saúde em Debate, Rio de Janeiro, v. 39, n. 104, p. 65-75, 2015. DOI: 10.1590/0103-110420151040348
https://doi.org/10.1590/0103-11042015104... ), when studying the perception of physicians working in three emergency hospitals, identified a professional profile of insufficient training for network care that points to the need for a research agenda in the field of human resources to delineate the general profile of physicians working in the services, subsidizing changes in undergraduate and graduate studies to meet the work demands within emergency care.

Regarding the relationship of users with hospitals in RUE, Sacoman (2019SACOMAN, T. M. Hiperutilizadores de baixo risco clínico em Pronto Socorro de um Hospital Universitário: usuários produzidos ou produtores de cuidado? 2019. 55 f. Dissertação (Mestrado em Ciências) - Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, 2019.), when studying the profile of frequent users in emergency rooms of a university hospital in the city of São Paulo (SP), identified that 3% can be considered super-users of low clinical risk, with their care corresponding to 10% of the service’s care production. In interviews with public administrators and service workers, the author realized that the reasons for super-use are: loyalty of the user due to an institutional linkage to specialized outpatient clinics; ineffective access to the service network; professional regulation performed by the hospital’s own workers; and low capacity of Primary Care to produce reception and bonding.

In a study conducted in a pediatric emergency room of a teaching hospital, Buboltz, Silveira, and Neves (2015BUBOLTZ, F. L.; SILVEIRA, A. da; NEVES, E. T. Estratégias de famílias de crianças atendidas em Pronto-Socorro pediátrico: a busca pela construção da integralidade. Texto & Contexto - Enfermagem, Florianópolis, v. 24, n. 4, p. 1027-1034, 2015. DOI: 10.1590/0104-0707201500002040014
https://doi.org/10.1590/0104-07072015000... ) identified that family members seek the emergency unit as their first choice of care, weaving alternative networks as a strategy to ensure quality care for their children, pointing to questions about the low resolution of Primary Care.

Thus, we can observe the centrality that hospitals still maintain in the RUE, when assessing sufficiency, network integration, access, and implementation of management tools, as well as the particularities regarding size and regional relations. The perceptions of users and workers also reinforce the symbolic capital of the hospital as the “main point of attention,” despite the frequent discourse demanding for integration and articulation within a network, as well as on the importance and limits of Primary Care. The implementation of arrangements and devices - such as Internal Regulatory Centers, Hospital Access and Quality Center, Risk Classification at emergency entry point, and Kanban - shows potential for transformation in the network care process, but relies on the action of local management and on processes involving multidisciplinary teams.

Final considerations

When observing the research developed in the last decade on RUE, we can see a production of dissertations, theses, and articles focused on its different components and on the integration between them, as well as perceptions and possible transformations in the health care process, working with different evaluation strategies and different approaches, mainly qualitative. This study showed a consistent production on the subject, despite presenting limitation on use of descriptors for the search strategies, whose expansion could result in the selection of other publications.

The RUE, as a thematic network in the context of the RAS, emerges as a proposal to overcome the fragmentation of care, promote network articulation and transform the care model, but also presents itself as an option to reduce the overcrowding on the entry points of health care. However, weaknesses are observed in this network articulation, maintaining the centrality of the hospital component and the power of its symbolic capital.

Among the components of RUE, most studies were on hospitals, UPA 24h, and SAMU 192. The studies on pre-hospital components mostly focused on regulation as a way to reduce hospital demand. Both UPA 24h and SAMU 192 can contribute to these results, depending on the arrangements and devices implemented in the regulation and coordination of care in services and territories. Nevertheless, fragmentation and the care model centered on “treat and street” has a tendency of being maintained if other strategies for coordinating care and networking are not implemented. Also in hospitals, the implementation of arrangements and qualification devices for care and management has potential for transformation in the care process, but depends on local management and processes involving the multidisciplinary team. Furthermore, such arrangements and devices could be strengthened if they were implemented from the perspective of networks.

Despite the recurrent discourse in the texts and statements of public administrators, workers, and users of the system regarding the relevance of Primary Care in RUE, this importance does not translate into reality. We observed few academic productions on the components for Primary Care and Home Care, most were focused on the care process at the point of care itself, even if the need for network articulations is indicated. This perception of Primary Care in the RUE is often contradictory within discourses: while its relevance, the need for investments, and even its centrality to the networks is recognized, the understanding of its limits and insufficiencies leads to the reinforcement of hospital-centered model.

In addition to structuring, investments in active and decentralized processes of integration, in management, in regional governance, and in health care are required for an effective implementation of RUE, thus guaranteeing its objectives. Giving thus rise to the perception that just introducing new services and formal devices into the network is not enough for the qualification and expansion of its integrality; whereas the focal point ought to be the implementation of articulation processes on the points of care and the qualification of care in emergency, encouraging and supporting the protagonism of local Workers and public administrators.

References

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