Hospital medicine, Brazilian style
Hospitalists describe how the growth of their field has made an impact on one country's health care system.
It has been over 15 years since the Brazilian Society of Hospital Medicine (SOBRAMH) held its first congress in May 2008 (see August 2008 Newman's Notions). In that time, hospital medicine has grown and spread throughout the country and has had an impressive impact, especially in one Brazilian state during the COVID-19 pandemic.
Brazil is a large country with almost 210 million inhabitants. Almost 75% of them rely on the public health system. There is a significant lack of coordination of care throughout the system, leading to overutilization and poor outcomes. The state of Espírito Santo, on the western coast north of Rio de Janeiro, has 4.1 million residents, of whom 72% depend on the public system for health care services.
The COVID-19 pandemic stretched already scarce resources and exposed structural inadequacies in the state's seven main public hospitals. Worsening the issue was a shortage of health care workers, especially nurses and physicians. In response, hospitalist leaders mentored by SOBRAMH changed the entire care model and implemented some basic hospital medicine principles. First, all doctors were paired with nurses to improve communication and quality and safety of care. Huddles, multidisciplinary rounds, and an intensive discharge plan were initiated. Bottlenecks for discharge were identified and solved quickly to avoid delays.
All of this, along with an intensive education program and more data-driven decision making, had a huge impact. The length of stay across all seven involved hospitals dropped 47% from 6.3 to 3.3 days over a two-year period, and a similar decline was seen specifically among patients with longer stays. At the same time, the mortality rate dropped 10%. In a situation where care is limited by insufficient resources, right-sizing the length of stay allowed many more patients to receive essential acute hospital care and removed unneeded strain on the Brazilian health care system.
There's potential for implementation of such a system throughout the country, or in other locations where there is no active coordinated hospital management. This project was only possible with the financial and administrative support of the Pan American Health Organization, the state government, and the Capixaba Institute. There was also significant support from the SOBRAMH, especially in educating a large number of physicians and other staff who were not familiar with hospital medicine concepts. Continuing to expand the reach of hospital medicine has great potential to help Brazil and many other countries face challenges in their health care systems.
