O Ministério da Saúde deve lançar ainda neste ano uma nova iniciativa em que a enfermagem poderá solicitar exames, realizar consultas e prescrever alguns remédios no SUS. As atividades são respaldadas por lei federal, mas enfrentam resistência dos conselhos médicos.
A proposta envolve a elaboração de novos protocolos de enfermagem e foi inspirada em experiências que já vigoram em outros países, como Reino Unido e Canadá, e em alguns municípios brasileiros.
Uma delas, em Jaraguá do Sul (SC), está entre as vencedoras de um prêmio da Opas (Organização Mundial de Saúde) e do Ministério da Saúde, que elegeu as melhores experiências para ampliar o acesso à atenção primária no SUS. O município adotou um protocolo de enfermagem criado na capital catarinense, Florianópolis, e, em seis meses, conseguiu zerar a fila de espera para a primeira consulta na atenção primária.
Segundo Erno Harzheim, secretário de Atenção Primária à Saúde do ministério, estão sendo elaborados protocolos para as principais condições de saúde em que enfermeiros apoiariam o médico.
O primeiro será de rastreamento de câncer de colo do útero e de mama e é baseado em protocolos já vigentes em Florianópolis e Porto Alegre. A enfermagem faz a consulta, o exame físico, a coleta do Papanicolaou e orienta a mulher sobre o resultado. Se houver lesão sugestiva de câncer, encaminha-a ao médico. No caso de câncer de mama, se a mamografia estiver normal, a enfermeira informa e orienta a mulher sobre a rotina de cuidados. Se existir alguma alteração suspeita, passa o caso para o médico.
Segundo Harzheim, os protocolos serão discutidos um a um com os conselhos federais de medicina e de enfermagem (CFM e Cofen). “Todos estarão ajustados às normas legais para que o enfermeiro possa trabalhar com alguns aspectos clínicos.”
Em nota, o CFM diz desconhecer a proposta do ministério e que foi chamado para se manifestar sobre ela. Reitera que, apesar de reconhecer a existência de protocolos específicos para ações no campo da saúde pública, a Lei do Ato Médico estabelece que o diagnóstico e a prescrição de tratamentos são atribuições exclusivas do médico. O médico Renato Tasca, coordenador de sistemas e serviços da Opas no Brasil, afirma que as doenças crônicas, como diabetes e hipertensão, já respondem por mais de 70% das causas de adoecimento do brasileiro, pondo os serviços de saúde “de joelhos”.
Por isso, diz, é essencial repensar o modelo de atenção à saúde. “Baseados em evidências científicas, os protocolos regulam e orientam o trabalho da enfermagem na atenção primária, permitindo ampliar o acesso, reduzir filas e agregar qualidade à atenção.”
Para o médico Drauzio Varella, colunista da Folha e um dos jurados do prêmio da Opas, os protocolos rompem a barreira do corporativismo médico ao atribuir à enfermagem papel relevante na atenção primária à saúde.
A capital pioneira na implantação no Brasil foi Florianópolis, em 2013, em parceria como Coren (Conselho Regional de Enfermagem de Santa Catarina). Desde então, houve um aumento de 38% do acesso aos serviços de saúde.
O enfermeiro já é responsável por até 90% do atendimento da demanda espontânea (consultas sem agendamento) e realiza 98% dos testes rápidos (para detecção de HIV e hepatite, por exemplo).
“Como grande parte da demanda espontânea já está nas mãos do enfermeiro, se ele consegue fazer a testagem, a gente tem ampliação e resolutividade do acesso”, diz Elizimara Siqueira, responsável pela enfermagem da rede municipal de Florianópolis e conselheira do Coren.
O tratamento inicial de sífilis na capital quase quadruplicou. Antes da adoção do protocolos de enfermagem, só 16% de casos eram tratados. Neste ano, foram 60% .
Enfermeiros fazem o teste rápido para detectar a doença e, se positivo, imediatamente medicam o paciente com penicilina. “Em 2018, todas as gestantes identificadas com sífilis foram acompanhadas e tratadas até o fim”, diz ela.
Os protocolos seguem recomendações do Ministério da Saúde e do Cofen e se baseiam em diretrizes de instituições renomadas como BMJ (British Medical Journal) e Cochrane (rede de cientistas independentes).
Em 2017, o CFM ingressou com ação judicial para proibir essas atividades da enfermagem sob alegação de que elas invadiriam as atribuições dos médicos. O caso foi arquivado.
Quase dois terços dos enfermeiros da capital catarinense têm formação adicional em medicina de família.
Quatro dos seis protocolos em vigor em Florianópolis, entre eles manejo de doenças crônicas, infecções sexualmente transmissíveis e saúde da mulher, já são adotados por 48 municípios catarinenses. Jaraguá do Sul, por exemplo, tinha há um ano fila de espera de 15,5 mil consultas. Com a adoção do protocolo, a fila para a primeira consulta foi zerada em maio.
Hoje, em 70% das consultas o usuário chega e é atendido pela enfermagem, sem esperar vaga em outro dia.
Segundo a enfermeira Silvia Regina Bonatto, gerente de atenção básica em Jaraguá, no início a proposta enfrentou desafios como a desconfiança da população de ser atendida por enfermeiros, além da resistência dos médicos.
Um ano depois, isso mudou. “Estamos trabalhando ombro a ombro com os médicos. Muitos que eram resistentes vieram nos cumprimentar.”
Mas há desafios a superar. A prescrição da enfermagem, por ora, não é aceita no programa federal Farmácia Popular, que oferta remédios essenciais gratuitamente ou a preço menor. Harzheim diz que a questão está em estudo.
Experiências no Rio e no Pará também são premiadas
Além da experiência de Jaraguá do Sul, outras duas foram eleitas as mais bem-sucedidas na área da atenção primária: uma na comunidade do Salgueiro (Rio de Janeiro) e outra em Abaetetuba (PA).
No Salgueiro, uma equipe de saúde da família fez um trabalho com crianças encaminhadas a serviços de saúde por alterações de comportamento no ambiente escolar, a maioria com diagnóstico de déficit de atenção e hiperatividade.
A proposta foi cuidar não só das crianças, mas também dos contextos familiar e social em que estavam inseridas. O trabalho envolveu famílias e educadores, conscientizando, entre outras coisas, para a cultura da não violência.
Em Abaetetuba, município com altos índices de mortalidade de mulheres em idade fértil, de gravidez na adolescência e de casos de sífilis, HIV e hepatites virais, o projeto envolveu ações de saúde com adolescentes, adultos e idosos, abordando sexualidade, valorização e respeito.
Houve aumento no número de atendimentos de pré-natal, atendimentos de saúde sexual e reprodutiva, testes rápidos de hepatite, sífilis e HIV, entre outros.
Por Folha Press
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Players will get to take on “hilarious missions” and “defeat epic bosses to collect medals and unlock dangerously superb outfits”. While that kind of customisation is certainly welcome, there will be a total of 23 customisable characters so it might take the completionists a while to kit out each and every one of them. The transition to the Switch hasn’t been a seamless one, though. Heavy compromises have been made, and strangely this is one of those games that I feel performs better handheld than docked. Frame rate keeps up most of the time to the game’s pace. Thankfully, it’s more often that you see dips due to the sheer numbers in the single-player mobs; multiplayer is for the most part stable. However, the majority of in-game cutscenes are ugly, with heavy texture and effect pop-in, alongside massive frame drops.
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