REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
SPECIAL
ARTICLE
Implementation
of
a
residency
program
in
anesthesiology
in
the
Northeast
of
Brazil:
impact
on
work
processes
and
professional
motivation
Cláudia
Regina
Fernandes
a,b,∗,
Rafael
Queiroz
de
Sousa
c,
Francisco
Sávio
Alves
Arcanjo
c,
Gerardo
Cristino
de
Menezes
Neto
a,c,
Josenília
Maria
Alves
Gomes
a,c,
Renata
Rocha
Barreto
Giaxa
daFaculdadedeMedicinadaUniversidadeFederaldoCeará(UFC),Fortaleza,CE,Brazil
bCentrodeEnsinoeTreinamento/MinistériodaEducac¸ão/SociedadeBrasileiradeAnestesiologia(CET/MEC/SBA),Hospital
UniversitárioWalterCantídio,UniversidadeFederaldoCeará(UFC),Fortaleza,CE,Brazil
cCET/MEC/SBA,SantaCasadeMisericórdiadeSobral,UniversidadeFederaldoCeará(UFC),Sobral,CE,Brazil dUniversidadedeFortaleza(UNIFOR),Fortaleza,CE,Brazil
Received12July2013;accepted20August2013 Availableonline2January2015
KEYWORDS
Medicalresidency; Mentoring; Anesthesiology; Perioperativecare
Abstract
Backgroundandobjectives: Tounderstand, throughthetheoryofsocialrepresentations,the influenceexertedbytheestablishmentofaresidencyprograminanesthesiologyonanesthetic careandprofessionalmotivationinatertiaryteachinghospitalintheNortheastofBrazil.
Method: Qualitativemethodology.Thetheoreticalframeworkcomprised thephenomenology andthesocialrepresentationtheory.Fivemultidisciplinaryfocusgroupswereformedwith17 healthprofessionals(fivesurgeons,fiveanesthesiologists,twonurses,andfivenursing tech-nicians),whoworkinoperatingroomsandpost-anesthesiacareunits,allwithaprioranda posterioriexperiencetotheestablishmentofresidency.
Results:Fromtheresponsecontentanalysis,thefollowingempiricalcategoriesemerged: moti-vationtoupgrade,recyclingofanesthesiologistsandimprovinganesthetic practice,resident asaninterdisciplinarylinkinperioperativecare,improvementsinthequalityofperioperative care,andrecognitionofweaknessesintheperioperativeprocess.Itwasevidentfromupper gastrointestinalbleedingsecondarytoprolongedintubationthatthecreationofaresidencyin anesthesiologybringsadvancementsthatarereflectedinthemotivationofanesthesiologists; theresidentworkedasaninterdisciplinarylinkbetweenthemultidisciplinaryteam;therewas recognitionofweaknessesinthesystem,whichwereidentifiedandactionstoovercomeitwere proposed.
∗Correspondingauthor.
E-mail:[email protected](C.R.Fernandes).
http://dx.doi.org/10.1016/j.bjane.2013.08.006
Conclusion:Theimplementationofaresidencyprograminanesthesiologyatatertiary educa-tionhospitalintheNortheastofBrazilpromotedscientificupdates,improvedthequalityof careandprocessesofinterdisciplinarycare,recognizedtheweaknessesoftheservice, devel-opedactionplansandsuggestedthatthistypeofinitiativemaybeusefulinremoteareasof developingcountries.
©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevier EditoraLtda.Allrights reserved.
PALAVRAS-CHAVE
Residênciamédica; Tutoria;
Anestesiologia; Assistência perioperatória
Implantac¸ãoderesidênciaemanestesiologianointeriordoNordestedoBrasil: impactonosprocessosdetrabalhoenamotivac¸ãoprofissional
Resumo
Justificativaeobjetivos: Compreender,pela teoria das representac¸ões sociais, ainfluência exercida pela implantac¸ão de um programa de residência em anestesiologia nos cuidados anestésicos e na motivac¸ão profissional em um hospital de ensino terciário do interior do NordestedoBrasil.
Método: Metodologiaqualitativa.Afenomenologiaeateoriadarepresentac¸ãosocialforamo referencialteórico.Formaram-secincogruposfocaismultidisciplinares,com17profissionais desaúde(cincocirurgiões,cincoanestesiologistas,duasenfermeirasecincotécnicosde enfer-magem)queatuamnoCentroCirúrgicoenaSaladeRecuperac¸ãoPós-Anestésica,todoscom experiênciaanterioreposterioràimplantac¸ãodareferidaresidência.
Resultados: Daanálisedeconteúdodasfalas,emergiram asseguintescategorias empíricas: motivac¸ão para atualizac¸ão, reciclagem dos profissionais anestesiologistas e melhoria das práticas anestésicas;oresidentecomo umelo interdisciplinarnoscuidadosperioperatórios; melhoriasnaqualidadedaassistênciaperioperatória;reconhecimentodefragilidadesno pro-cesso perioperatório.Evidenciou-sequeacriac¸ãodeuma residênciaem anestesiologiatraz avanc¸os,queserefletemnamotivac¸ãodosanestesiologistas;oresidentefuncionoucomoum elointerdisciplinarentreaequipemultiprofissional;houvereconhecimentodefragilidadesdo sistema,identificaram-seasdeficiênciaseapontaram-seac¸õesparasuperac¸ão.
Conclusão:Aimplantac¸ãodeumprogramaderesidênciaemanestesiologiaemumhospitalde ensinoterciáriodointeriordoNordestedoBrasilpromoveuatualizac¸õescientíficas,melhorou aqualidadedaassistênciaeosprocessosdecuidadosinterdisciplinares,reconheceuas fragili-dadesdoservic¸o,desenvolveuplanosdeac¸ãoesugeriuqueessetipodeiniciativapodeserútil emáreasremotasdepaísesemdesenvolvimento.
©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
Residencyisatrainingprogramforlong-termservice, rec-ognizedas thebestmechanism for trainingphysicians for specialized,responsible,andqualityprofessionalpractice. Given the need to expand the residency to meet the demands of specialists in strategic areas and regions for theSistemaÚnicodeSaúde---SUS(UnifiedHealthSystem), the Ministries of Health and Education have developed a jointefforttofund newprogramstopromotethis expan-sioninanorderlymanner,inlinewiththeresolutionsofthe ComissãoNacionaldeResidênciaMédica---CNRM(National MedicalResidencyCommittee).1Studiesconductedin2005,
and repeatedin 2006 and 2008, reported a high concen-tration of programs and institutions offering residency in theSoutheastandSouthregions,respectively.The concen-tration of vacancies andscholarships for residency in the
Southeastregioncoincideswiththeconcentrationofother health indicators. National studies have shown the over-lappercentageofpracticingphysiciansoverthenumberof vacanciesandscholarshipsresidencyaccordingtotheregion inBrazil.2 The supplyofnewresidency centerswith
qual-ity programs helps to keep doctors in the regions where theyattendedtheresidency.AstudypublishedintheNew EnglandJournalofMedicine,3in2010,confirmssomeofthe
datacollectedbetween2004and2008inBrazil.2Similarly,
studiesconductedin Canadaconfirmmedicalresidencyas afactor forkeepingphysicianseveninareasmoredistant fromthatcountry.4
launchedin October 2009, constitutes a milestonein the establishment of a public policy to foster specialized medical training, from the health needs of the country, andprovides accreditation ofnew programsundermatrix support.2
Matrix support is a complementary arrangement built fromtheestablishmentofaspecializedrearguardofsupport tomatrixinstitutions.Ithasthepurposeofco-responsibility, withtechnical and pedagogicalfunction, with technology transferforteamqualification.4
Astudyofthedistributionofspecialistsonthenational scene indicated the anesthesiology specialtyas a priority intheNortheast.In 2010,thefirstMedicalResidency Pro-gram (MRP) in Anesthesiology began in the Northeast of Brazilundermatrix support, accreditedby theMinistryof EducationandtheBrazilianSocietyofAnesthesiology.
The aim of thisstudy wastoevaluatethe influenceof an AnesthesiologyResidencyProgramimplementationat a tertiaryteachinghospitalintheNortheastofBrazilonthe processesand anesthetic care, throughthe perception of health professionals who have worked in this sector and experiencedthistransitionperiod.
Method
Thisstudyusedatheoreticalandmethodologicalapproach givenby qualitative-phenomenologicalresearch5---7 on
per-ceptions of health professionals working in the operating roomand post-anesthesiacare unitof SantaCasade Mis-ericordiadeSobral(Teaching HospitaloftheUniversidade FederaldoCeará---CampusSobral),andwhether anesthesi-ologists,surgeons, nurses,andnursing assistantsregarded the change and evolution of processes occurring in the following sectors: operating room (OR), post-anesthesia care unit (PACU), and anesthesiology service, from the establishment of the anesthesiology residency. The social representation theory8,9 allowed the understanding of
the transformationphenomenon that a medicalresidency implantationcanexerciseinaserviceorsector.
Selectionprocessandsample
Seventeenhealthprofessionalswereinterviewed(five sur-geons, fiveanesthesiologists,twonurses, andfivenursing technicians)duringtheirworkinghours.Theinterviewstook placeinaprivateroomnexttotheoperatingroom.The sam-plewasselectedbyconvenienceandthe‘‘saturationpoint’’ wasconsidered,whichissetwhentheinterviewerrealizes thatthereisnonewinformationtobeheard.Participants werehealthprofessionalsworkingintheORandPACU,all withboth anteriorandposterior experiencetothe estab-lishmentoftheanesthesiologyresidencyandwhowillingly acceptedtheinvitationtoparticipateinthestudy. Profes-sionalswhohadnoexperienceprevioustotheestablishment ofresidencywereexcluded.
Selected professionals were allocated into multidis-ciplinary focus groups. Professional categories included anesthesiologists,surgeons(traumatologists,obstetricians, general surgeons, and neurosurgeons) and nursing staff (nursesandnursetechnicians).Eachfocusgroupconsisted offourtosixparticipants,withatleastonememberofeach
category.Theentirespeechwasfree,withoutinterruption madebytheobserver,volunteersspokerandomly,therewas dialogbetweenthem,butwiththeparticipationofall.The responses wererecorded andtranscribed for analysisand subsequentlyclassifiedintocategoriesbyfrequencycount.9
The research adopted measures to preserve the con-fidentiality, anonymity, and privacy of respondents. Their fullnames were restricted toinformedconsentsigned by all.Themethodologicalprocedureswereexplainedtothe respondentsindividually,includingthe possibilityto inter-rupt,answerthequestionsornot,andtherighttorefuseto participate.
The project wasreviewed and approved by the Ethics CommitteeoftheHospital.
Researchinstrument
Thedatacollectioninstrumentusedwasasemi-structured interviewwithfiveguidingquestionsafterbeginningthe res-idencyinanesthesiology:(1)Wasthereachangeinsurgical centerroutine?(2)Wasthereanyimprovementinthe qual-ityof anesthesia care? (3) Was there an incorporation of newanesthetictechniques?(4)Wastherechangesin inter-disciplinaryrelationships?(5)Whatcouldbeimprovedinthe implantedresidency?
Dataanalysis
Afterduetranscription,thedataandinformationcollected in the speech of health professionals in the focus groups wereanalyzedfor theircontentbasedonsocial represen-tation theory. We sought to explore the structures that respondents expressed as relevant. Nonverbal elements expressedby respondentsweretaken intoaccountat the timeofcollectionandanalysisofdata.5
Results
The categorieslisted below emergedfromthe analysisof thefocusgroups:
Upgrademotivation,recyclingofanesthesiologists, andimprovementinanestheticpractice
It was emphasized that the institution’sanesthesiologists weremotivated by thepresence of the medicalresident, whichrevivedinterestinupdatingandtheneedtoengage in processesof continuing education. There was satisfac-tionwiththe creation of protected timefor didactic and scientificdevelopment,suchasseminarsandlectureswith differentguests.Thiswasevidencedbythefollowing state-ments:
In terms of learning, it was a great encouragement
to study, fly higher flights when caring more severe
patients, with the exchange ofexperiences with
resi-dents.(Anesthesiologist)
encouragedbytheconstantpresenceofresidentsinthese events.
Muchhaschangedintermsofeducation.Theprofessors
themselvesstartedtostudymore,bemorecarefulwith
the anesthetic routines. They attended more
confer-encesandbroughtinnovations,renewtheservice.There
was a substantial change, the anesthesiology service
improvedandincreasedby 60%to80% afterthe
Anes-thesiologyResidencyimplementation.(Surgeon)
Theacquisitionandimprovementofequipment,aswell asthesurgicalcenterstructure,weretopicsofmuch discus-sionamongfocusgroupsandrecurrentopinioninspeech:
New appliances were purchased; there was a full
recyclingofprofessionalanesthetists,scrappedmaterial
wasreplaced.(Surgeon)
Withthearrivalofresidentstotheinstitution,theuseof avariabilityofanesthetictechniquesincreased,whichwere knownbytheprofessionals,butwereunderusedduetothe immensesurgical demandthat overloadedthem,resulting insomedegreeofweaknessinthequalityofcareoffered.
We already knew the anesthetic procedures, such as
placementofepiduralcathetersinmajorsurgeries,but
residentsstartedtomotivateustoperformthis
proce-dure;because,toshortentheanestheticprocedure,our
initiativewasalwaystheadministrationofgeneral
anes-thesiawe did not have a closer look atpostoperative
pain.Therewasasignificantincreaseinqualityofcare withtheintroductionofepiduralcatheters[. . .]Another
importanttypeofmonitoringfortheservicewastheBIS.
Webegantouse thisequipment withthe
implementa-tionoftheResidencyProgram.Weknewofitsexistence
throughliterature,butwiththeresidentsarrivalitwas putintooperation.(Anesthesiologist)
Similarto surgeonsand anesthesiologists,nursing staff also recognizedthe evolution and improvement involving anesthetictechniques andalsohighlightedthebenefits to patientsfromtheuseofepiduralcathetersinhigh complex-itysurgeries,withpositiveeffectsonpostoperative acute painmanagement.
Theuseofepiduralcatheterinmajorsurgeryisaplus,
abigimprovementforpatientspostoperatively, thisis
verygood.(Nurse)
Theresidentasaninterdisciplinarylinkin perioperativecare
Inthiscategory,theimprovementofdialogbetweensurgeon andanesthesiologistabouttheplanningandchoiceof anes-thetictechniquebasedontheproposedsurgicalprocedure wasobservedrepeatedly.
Therewasmoreinteractionbetweentheprofessor
anes-thetistand surgeon aboutthe surgical procedure. The
possibility of a particular anesthetic technique for a
givenprocedurewassuggested.I’vefeltit;thereis ques-tioningwiththeresidents.(Surgeon)
Thisstatementsuggeststhatbybringingquestions,the presenceofresidentsencouragesdialogandcontributesto
a shareddecision-making between thepreceptor of anes-thesiologyandthesurgeon,withtheeffectiveparticipation ofresidents.
Improvementininterdisciplinaryrelationand communi-cationprocessesextendedtothenursingstaff.
Theresidentsherewithusbecamealinkbetweennurses, surgeons,andanesthetists.(Nursing)
Minimizingconflictsinthesurgicalenvironmentwasalso mentioned:
Thereusedtobemoreconflictintheoperatingrooms.
Withresidents,itdisappeared,involvingtheeducational part.(Anesthesiologist)
Improvementsinthequalityofperioperativecare
The improved quality of care for patients after the Anesthesiology Residency Program implantation was fre-quentlymentioned,withinductionofreflectivepracticeby teachers,motivatednotonlybyconstantinquiriesand ques-tionsfromresidentsbutalsothroughamorecomprehensive andintegrated approachtopatients,ratherthan apurely technicalandintraoperativeapproach.Theseissuescanbe seeninthefollowingstatements:
Preanestheticvisitismadebyresidents[. . .]thisisaplus
foranesthesiaservicequalification.(Surgeon)
Thisstatementaddressesanimportantaspectofquality ofcare,asthepreanestheticevaluation,withknowledgeof theclinicalconditionofthepatientbeforetheprocedure,is mandatoryundertheresolutionofCFMN◦1802/2006,
espe-ciallytoassessrisks,outlineanappropriateanestheticplan, andmaketheproceduresafer.
The presence of the anesthesiology resident at the service facilitatedtheachievement ofperioperative care, and preanestheticevaluation wasa highlight, with subse-quentdiscussionofcaseswithprofessors,astheywerefew innumbercomparedtothelargesurgicaldemand,andhad notimeavailabletoprovideadequatepreoperativecareto patientseligibleforelectivesurgeries.
Ourteamissmallandthereareoverathousandsurgeries permonth[. . .],weenduprushingandsimplifyingthe
processes.Majorsurgeryindicatedforepiduralcatheter
end upnot beingmade dueto lackoftime. Residents
havemadethisprocedurefeasible withus.
(Anesthesi-ologist)
Preanestheticvisitismadebytheresidentsandthisisa gaininqualifyingtheanesthesiaservice.(Surgeon)
Prior assessment ofcases, withdiscussion with profes-sors,andthecreationofananestheticplanthatimproves intraoperativemonitoringprovidedafavorableenvironment for care systematization,increasesthe safetyof anesthe-sia,andimprovedqualityofcare.Theseconsiderationsare clearlyevidentinthespeeches:
Regarding monitoring, care,and the wholeprocedure,
thepatientwasmuchbettercaredfor.(Anesthesiologist)
Inoticethattheytalktous; theyrequestwhateveris
ismissing: medication,catheter, tube; they go tothe nursingdepartmentandaskfor.(Nurse)
Recognitionofweaknessesintheperioperative process
Theweakestpointoftheperioperativecareprocessshown in this study is related to the Post-Anesthesia Care Unit (PACU).Thereareseveralreasons,suchastheoverheadof surgerybecauseitis atertiaryreferral hospitalfor emer-gencyandhighcomplexity.Thehospitalserves55northern municipalitiesoftheStateofCearáandthereisnowayto regulatethenumberofpatientswhoaresent toit,which leadstoovercrowding,lackofhumanresourcestomeetthe demand,reflectingonthequalityofcareinthe postopera-tive period, in addition to not having an anesthesiologist on duty exclusively in the PACU. It is under the care of the nursing team, under the supervision of anesthesiolo-gistswhoworkintheoperatingroom,asrepresentedinthe speeches:
Thenumberonepointthatneedsurgentrestructuringis
thePACU.(Surgeon)
Wewishtherewasgreaterinvolvementofphysicians
inrecovery,follow-up,andpostoperativecare,asdoes
theexclusivephysicianofPACU.(Nurse)
Duetothemarkeddemand,therecoveryroomneeds
tobebetterstructured;itisoneofthemajorstigmasof
SantaCasa,oneofthegreat challengesthatsurgeons,
anesthesiologists, andresidentsface [. . .] itis agreat
battle.(Surgeon)
Ithink thatananesthesiologisttocareonlyforthe recoveryroomislackinginthesector,andthisisaserious mistake[. . .]regardingPACU,weneedmoreequipment,
in addition to an anesthesiologist onlyfor the sector,
weneedtoincreasethenursingstafftomeettherising
demand.(Anesthesiologist)
Peroperatively, the urgency of establishing a more
regularpreanestheticroutine,withthepossiblecreation ofaspecificclinic,isalsoarecurringdiscourse.
Outpatientpreanestheticservice,ithelpstoreduce
thenumberofsuspendedsurgeries.(Nurse)
IknowIcannotperformthepreanestheticevaluation inallpatients,butsomeareelderlypatientsundergoing
surgeryforfemoralneckfracture,andpost-anesthetic
. . . wereallymissseeingit.(Surgeon)
First thing, improve the pre-anesthetic visit.
Pre-anestheticvisitneedstobeimproved.(Anesthesiologist)
Article 1ofthe ConselhoFederaldeMedicina(Federal Councilof Medicine)resolution,N◦ 1802/2006, statesthat
‘‘Beforeperforming any anesthesia, except in emergency situations,it isessential toknow,inadvance, theclinical conditionsof the patient, leavingup tothe anesthesiolo-gistthedecisiononthedesirabilityornotoftheanesthetic act,in asovereignand non-transferableway:forelective procedures,itisrecommendedthatthepreanesthetic eval-uationisperformedduringthemedicalconsultationpriorto admission’’.
Discussion
Residencyisunderstoodasaspacefortrainingand contin-uingeducation,which maynotbelimitedtoaconception ofeducationalspecializationprojectalone.Residencyalso maynot be seen only as a work process.The complexity ofitsnatureand theindissociability ofthesetwoaspects highlightedmark a uniqueandveryinteresting featureof residency:therecognition andappreciationof theroleof work as a key teaching tool of a professional.10 Within
thiscontextareboththe preceptorof anesthesiologyand theapprenticeresident; thereisan inseparableexchange ofknowledge andabilateral processof teaching/learning that undoubtedly contributes to improve the quality of care.
TheCNRMN◦02/2006ResolutionofMay17,2006provides
forminimumrequirementsofmedicalresidencyprograms, aswellastheBrazilian SocietyofAnesthesiology provides for theregulation of Centers for Education andTraining11
thatinevitably leads toprogress andimprovement in ser-vicesthatpurporttobeexperttrainers.Thus,theexpected naturalhistoryofaservicethathostsaresidencyprogram istheproduction ofemancipationandimprovement inall aspects,includingthemanagementofacutepostoperative pain.12
The perception that residents, when properly super-vised,bringimprovementsinqualityofcarecomesnotonly fromhealthprofessionalswhoworkandliveinthesector; patientsalso perceivethe qualityof services providedby residentsundersupervisionandareverysatisfied,as pub-lishedevidence.13
Studies showthat theprocessesof communicationand integrationamongworkteams,particularlybetween anes-thesiologistandsurgeon,improvetheeffectivenessofthe resultsandqualityofservicesprovidedtopatients, impact-ingonorganizationalcultureservices.14
It is known that no professional has all tools to meet the health problems, there must be an interdisciplinary approachfor an effective teamwork. This may be under-stoodasintegratedactionswithacommonpurposebetween professionalswithdifferent areas of training.This is pos-sible through the recognition of the specificities of each professional,achieved with continuous dialog, seeking to overcomethefragmentation ofknowledge andservices.15
The presence of a resident in anesthesia served as a link for the nursing staff and facilitated access to infor-mation about anesthetic techniques planned for certain surgicalprocedure,andalsoforfurtherclarificationofthe patient’s clinical condition. It was thus seen as improve-ment in care, with more detailed and closer approach to the patient, with the adoption of a multidisciplinary approach.
Thenewdirectionsofanesthesiologyasaspecialty stim-ulatetheadoptionoftheperioperativemedicinepractice, whosepredominantassumptionofcareisbasedonpatient safety.Inthiscontext,interprofessionaleducationenables thejointlearningofteammembersandpromotesaculture ofsafety.16 Forthis,the adoptionof a competence-based
curriculumisessentialinthisneweducationalprocess.The Anesthesiology Residency at the Santa Casa de
Misericór-dia de (city of) Sobral began planned in the light of a
Surgery and anesthesiology have always been closely intertwined. Inside the growing complexity of therapies and technical skills, disciplines overlap in certain areas. Themostimportantistounderstandthatthemedical spe-cialtiesarenotcompetitors,butpartners.Evidenceshows thatsurgicaloutcomescan beimprovedthrougheffective communication and interactionbetween anesthesiologists andsurgeonsinmultidisciplinaryteams,whichishighly ben-eficialforpatients.18
The presence of the resident can be a driving fac-torofprofessionals’reflectivepractice,understoodasthe abilitytocritically reflectontheirownthinkingand deci-sions. It motivates the professional to ‘‘perform well’’ their activities and causes him to revise his knowledge, study,and‘‘thinkaloud’’.Theseactionsdecreasethe auto-maticityofpracticeanddrivetheanalyticalreasoningand ongoingtraining.Consequently,therearereducederrorsof cognition.19
Positiveattitudesofinterrelationshipandbehavior trans-form the workplace and create a favorable atmosphere for adoption of safety checklist proposed by the World Health Organization,20 as the high prevalence of adverse
effectsfound anddocumentedin hospitalsin Latin Amer-icainfersthat patientsafetymay representan important publichealth problem,as hasbeen documentedin North America.21
PACUrequirementinhospitalsinBrazilwasdetermined byOrdinance400oftheMinistryofHealthin1977,A Res-olutionofthe FederalCouncil ofMedicine, N◦ 1802/2006,
which regulates the practiceof anesthesia, and states in Article IV that ‘‘after anesthesia, the patient should be transferredtothepost-anesthesiacareunit(PACU)or inten-sivecareunit(ICU),asappropriate’’.Itfurtherprovidesthat ‘‘PACUdischargedisthesoleresponsibilityofthe anesthe-siologist’’;andthat‘‘inPACU,fromadmissiontodischarge, patientsremainmonitoredfor:circulation,including mea-surementofblood pressureandheartrateandcontinuous determination of cardiac rhythm by cardioscopy; breath-ing, including continuous measurement of arterial blood gas and pulse oximetry; state of consciousness;and pain severity’’.
InastudyconductedinBrazil,in2003,onpost-anesthetic care routine of Brazilian anesthesiologists, it was shown that the availability of equipment in PACU grew progres-sivelyfor practicing anesthesiologists in North/Northeast, Midwest, South, and Southeast regions. The residency program at the institution wasassociated with the exist-ence of an anesthesiologist on duty 24h in PACU and the availability of resuscitation equipment and others, such as peripheral nerve stimulator and active heat-ing system.22 It is assumed that the existence of a
residency program induces improvements in quality of service.
Regarding pre-anesthetic care, the outpatient visit for preanestheticassessment is extremely important in order to stratify risk and plan better for intraoperative and monitoring care, which contributes to increased safety of anesthesia, maintenance of ties, and clarifies ques-tionsof patients, reducing the rateof surgery suspension and increasing customer satisfaction.23 In this study, this
is a weakness of the service that needs to be better structured.
Conclusions
The influence of the implantation of the Residency Pro-gram in Anesthesiology at a tertiary teaching hospital in the Northeast of Brazil reflected in the anesthetic pro-cess and care and in the motivation of anesthesiologists whoworkedintheinstitutionforprofessionaldevelopment, recycling, and implementing improvements in anesthetic practice. The resident presence worked as an interdisci-plinarylinkbetweenanesthesiologists,surgeons,andnurses andgreatlyimprovedpatientperioperativecareandsafety. However,reflectingontheprocessflowandqualityofcare, there was recognition of the weaknesses related to pre-andpost-anestheticcare,identificationofthedeficiencies andactionstoovercomethem.Aresidencyprogram,whose implementationwasplanned asa participativeprocess of anesthesiologists who make up the clinical staff, yields groupmotivationandresultsinadvances,scientificupdates, reflections oncare processes, improvements in quality of care, recognizing weaknesses and development of action plans topromotecontinuousadvancesin education,care, andassistance.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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