Checklists na saúde podem reduzir mortalidade em 45%

Dr. Omar Mejía, do InCor

Assista à palestra “Segurança do Paciente Cirúrgico”, do Dr. Omar Mejía, no canal do AnestEdu no YouTube

De vez em quando, aparece na internet um texto sobre a importância de se fazer listas. O site da BBC Brasil, por exemplo, publicou uma matéria com sete razões pelas quais fazer listas pode mudar sua vida, entre elas as de que listas podem torná-lo mais bem-sucedido, ajudam a economizar, a manter o foco e a prevenir erros. A essas razões, podemos juntar: listas podem salvar vidas. Segundo o Dr. Omar Asdrúbal Mejía, cirurgião cardiovascular e diretor associado da Unidade Cirúrgica de Qualidade e Segurança do O Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da USP, um estudo um estudo comprovou que a aplicação de um ckecklist em todos os tipos de cirurgia pode diminuir a mortalidade em até 45%. Na palestra “Segurança do Paciente Cirúrgico”, no 8º AnestEdu,

o Dr. Mejía contou que o estudo, A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population [Checklist de Segurança Cirúrgica para Reduzir a Morbidade e a Mortalidade em uma População Global], realizado em mais de oitocentos centros de saúde de várias regiões no mundo – desde a Tanzânia rural até Seattle, nos Estados Unidos –, aplicou um instrumento complexo usado na aviação: “O impacto foi gigante. Com a aplicação do checklist em todos os tipos de cirurgia, a mortalidade caiu quase 45%. Não há nada, atualmente, nenhuma medicação, que traga esse resultado. É a aplicação de um sistema que faz medições e evita que o fator humano influencie o resultado”.

Veja também: Futuro da gestão hospitalar está na transparência e no trabalho em equipe, alerta o Dr. Omar Mejía, do InCor

Ele falou de alguns modelos de checklist. Em um deles, há 28 itens a serem aplicados antes da indução anestésica, da incisão cirúrgica e de o paciente ser retirado do centro cirúrgico. É uma verificação que pode ser feita em dois minutos e nela, por exemplo, o antibiótico é administrado até meia-hora ou uma hora antes do procedimento. Com isso, a taxa de infecção cai 50%, o que é importantíssimo, dado que 2 milhões de pessoas por ano podem ter infecções adquiridas, resultando em uma taxa de mortalidade alta.

Checklist de Segurança Cirúrgica da Organização Mundial da Saúde
Checklist usado no Hospital Johns Hopkins, em Baltimore, Maryland, Estados Unidos

O Dr. Mejía adverte, no entanto, que é preciso ter organização, pois a aplicação dos checklists é muito complexa e não há checklist que funcione se não houver pausas: “‘Eu fiz o checklist! Ok, onde está? Tem que assinar.’ Não conseguimos ver o checklist, ele está no hospital, mas muitas vezes está no quadro na parede e ninguém sabe quando é aplicado”.

Checklist na aviação, trabalho em equipe e análise de dados na saúde

As comparações entre a saúde e a aviação sempre surgem quando o assunto é segurança. Para o Dr. Omar Mejía, o diferencial da aviação em relação à saúde é o uso eficiente da ferramenta de checklist e da habilidade não técnica de trabalhar em sistema e em equipe. Ele contou que fez uma prótese transfemural em uma paciente e ela lhe disse que queria se recuperar logo porque dali a uma semana iria viajar para ver a aurora boreal. O Dr. Mejía então lhe perguntou se ela sabia em que avião iria viajar, mas nem ela nem a filha, que a acompanhava, sabiam. “Essa é a sensação de segurança que a aviação proporciona. Eu vou viajar, simples assim!”

Segundo a Aviation Safety Network, organização holandesa que monitora acidentes aéreos no mundo, 2017 foi o ano mais seguro da história da aviação e registrou dez acidentes em linhas comerciais, com menos de cinquenta mortes. O mesmo ano, porém, segundo uma reportagem publicada em novembro de 2017, viu três pessoas morrerem a cada cinco minutos nos hospitais brasileiros por erros evitáveis. O que a aviação tem que a saúde não tem? “Eles têm tecnologia? Nós também temos. Eles têm treinamento? O cirurgião também. O que eles têm é chekclists! Eles checam, eles se autocriticam, sabem que são limitados”, declarou o Dr. Mejía.

Veja também: Avaliação pré-anestésica: grande aliada na era da remuneração por performance

Para ele, muitos profissionais de saúde, médicos anestesistas, cirurgiões, não aderem ao checklist porque não estão inseridos em um sistema, não se sentem parte de uma equipe. Na formação para a Saúde, aprenderam que tinham de fazer tudo e ser ousados e corajosos para tratar o paciente. “Mas a ciência nos trouxe um grande problema: precisamos nos entender em sistema porque, do contrário, o custo é alto. Sem sistema, o desperdício aumenta. Precisamos entender que juntos podemos alcançar mais.”

Outra necessidade primordial é coletar e analisar dados. Por exemplo, segundo o Dr. Mejía, atualmente o número de eventos menores por cirurgia congênita do coração chega a quinze, e de eventos maiores é de dois ou três. Esses eventos são percebidos porque os profissionais são experientes, há preparo cognitivo dos cirurgiões que são treinados, dos médicos anestesistas, da equipe, mas “o que não é definido não pode ser medido. O que não pode ser medido, não pode ser melhorado. O que não pode ser melhorado, sempre irá se deteriorar”. Foi o guru da gestão Peter Drucker que disse algo semelhante, e é verdade. “Você não melhora processos se não tiver dados, é um círculo virtuoso. Se vai implantar uma iniciativa de qualidade, além de adaptá-la para seu hospital, você tem que medir para saber os resultados, pois todos influenciamos os resultados”, afirmou o Dr. Mejía.

Checklist evita erros e aumenta qualidade na saúde

O Dr. Omar Mejía contou também que quando começou a aprender sobre qualidade na saúde, em Boston, nos Estados Unidos, teve um professor que na primeira vez que entrou na sala de aula, disse: “Quem acha que não erra, pode sair, é parte do problema”.

“Todos erramos. Todos os dias. Só que a gente não aprende com o erro, a gente esconde o erro. Isso é cultural e precisa mudar”, disse o Dr. Mejía. E quando há erros, procura-se apontar culpados: “Na aviação, já compreenderam que quando ocorre um problema, a culpa não é de uma pessoa ou de uma área apenas, mas de um sistema.”

Para o cirurgião cardiovascular, a meta para quem trabalha em saúde é uma só: foco sobre o paciente, é preciso que todos os profissionais se empenhem em caminhar juntos em prol do paciente. O fator humano é vital, não há como focar apenas a técnica.

Veja também: Como levar seu hospital à excelência: a importância das habilidades não técnicas

“Precisamos focar as habilidades não técnicas”, disse o Dr. Mejía. Ele falou de dois volumes lançados pela Universidade de Aberdeen, na Escócia, trabalho da Dra. Rhona Flin e desenvolvido com auxílio de conceitos de segurança da aviação: Framework for Observing and Rating Anaesthetists’ Non-Technical Skills – Team Working, Task Management, Situation Awareness, Decision Making [Modelo para Observação e Avaliação das Habilidades Não Técnicas de Anestesistas – Trabalho em equipe, gerenciamento de tarefas, conscientização de situação, tomada de decisão] e The Non-Technical Skills for Surgeons (NOTSS) – Team Working, Task Management, Situation Awarness, Decision Makin – Structuring observation, rating and feedback of surgeons’n behaviours in the operating theater [Habilidades Não Técnicas para Cirurgiões (HNTC) – Trabalho em equipe, gerenciamento de tarefas, conscientização de situação, tomada de decisão – Modelo para Observação, Avaliação e Feedback do Comportamento de Cirurgiões em Centro Cirúrgico]. “Em saúde, ainda precisamos avançar muito no trabalho em equipe. Daqui para a frente, não poderemos apenas realizar, teremos que realizar com qualidade”, disse o Dr. Mejía.

Ele disse que a questão da qualidade na saúde não é nova, mas vem se desenvolvendo há muito tempo, e teve um de seus pioneiros em Boston, o Dr. Ernerst Amory Codman (1869 – 1940), fundador do hospital de desfechos finais. Foi quando nasceu também a Joint Commission. Desde então, ocorre uma cadeia evolutiva em que saímos da paralisia explicativa, no início do século 20, quando a qualidade na saúde era inexistente, passando pelo círculo vicioso entre início e meados e do século 20 (qualidade baixa), melhoria por problema entre meados do século 20 e década de 1990 (qualidade média), melhoria contínua entre a década de 1990 e o início do século 21, finalmente alcançando uma qualidade alta e chegando ao ponto em que nos encontramos, o de inovação, da pós-qualidade.

Para o Dr. Mejía, inovação não é só inventar algo que ninguém nunca viu: “Inovação é mudar o modelo, o resultado, diminuir custo, melhorar a qualidade, e Codman fez essa proposição de que a qualidade é melhor com custo baixo, o que parece uma coisa irreal, mas atualmente é o que mais se utiliza para melhorar processos em qualquer tipo de linha de pesquisa”, afirmou. “Qualidade é o aumento das possibilidades de alcançar os resultados desejados, e a segurança faz parte disso. Um hospital com qualidade se preocupa com segurança, se preocupa em analisar onde agir para evitar complicações.”

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