Demanda x capacidade instalada: contribuições do LM no enfrentamento da crise na hemodiálise de um hospital público
Arquivos
Data
2018-03-01
Autores
Masiero, Cristiane Parisoto
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Editor
Universidade Estadual Paulista (Unesp)
Resumo
RESUMO Introdução: A doença renal crônica é um problema de saúde pública global e vem apresentando uma tendência de crescimento. Quando a capacidade renal atinge parâmetros entre 10 e 15%, é necessária a realização de uma terapia renal substituitiva. No hospital em questão, o centro de hemodiálise se encontra com sua capacidade total instalada e a demanda por vagas continua. Os pacientes então começaram a ser internados aguardando pela vaga ambulatorial por períodos que podem chegar a 3 meses. A opção internação pela internação, que pareceu funcionar bem no início, logo criou novas interações antes inexistentes, além de consequências para os pacientes, como infecção hospitalar e depressão. Objetivo: Contribuir para a implementação de novas metodologias participativas na busca por soluções coletivas que atinjam os determinantes organizacionais nas atividades da área de saúde. Método: Foi utilizado o Laboratório de Mudanças (LM) que possui como base a teoria histórico cultural e o princípio da dupla estimulação e visa a construção coletiva de soluções. O trabalho foi dividido em duas fases: uma de coleta de dados etnográficos, com entrevistas individuais e coletivas, observação in loco e exame de documentos. Na segunda fase foram realizadas oito sessões do LM com um grupo composto em média por quinze pessoas do setor de terapia renal substitutiva e os setores que passaram a interagir após a internação dos pacientes. Resultados: A análise da atividade atual demonstrou que os pacientes com problemas renais continuam chegando ao hospital por diversas vias e que os profissionais não possuíam autonomia para negar o paciente pela falta de vaga. A equipe absorve essa demanda e sofre o impacto inicial é a que atende a insuficiência renal aguda (IRA) e equipe a de nefrologistas. Dados históricos demonstram que a equipe se manteve a mesma ao passo que o número de pacientes triplicou. Foram sendo arranjados locais para esses pacientes serem dialisados, ocupando outro setor, o do Centro de Terapia Intensiva (CTI), também com a capacidade esgotada. Essas mudanças levaram a contradições secundárias no sistema de atividade que emergiram durante as sessões do LM. As sessões proporcionaram um momento para discussão desses problemas, a mudança de alguns componentes do grupo para uma visão mais sistêmica da situação e a formação de agência de parte dos envolvidos. Após passar pelas fases de questionamento e construção histórica da atividade, houve a elaboração de proposta de novo modelo mais voltado para o método de diálise peritoneal, onde há maior autonomia do paciente, que pode realizar a diálise em sua casa. A prevenção também foi foco de discussão. Conclusão: O Laboratório de Mudanças proporcionou que os participantes ampliassem a compreensão dos problemas vivenciados pelo setor de hemodiálise de forma pessoal para sistêmica. Também possibilitou micro ciclos de aprendizagem expansiva, porém de forma diferente nos diversos atores. Houve a criação de agência manifestadas nas sessões e também fora dela. O LM demonstrou ser um importante método para a construção de mudanças organizacionais de forma coletiva.
ABSTRACT Introduction: Chronic kidney disease is a global public health problem and the tendency seems to increase. When renal capacity reaches parameters between 10 and 15%, renal replacement therapy is necessary. At the hospital in this study, the hemodialysis center has its full capacity installed and the demand for vacancies continues. The patients then began to be hospitalized waiting for the outpatient vacancy for periods that can reach 3 months. The hospitalization option, which seemed to work well in the beginning, soon created new interactions that did not exist before, as well as consequences for the patients, such as hospital infection and depression. Objective: To contribute to the implementation of new collaborative methodologies in the search for collective solutions of organizational determinants in health activities. Method: It was applied the Change Laboratory (CL) Method based on cultural historical theory and the principle of double stimulation that aims the collective construction of solutions. The study was divided in two phases: one of ethnographic data collection, with individual and collective interviews, on-site observation and documents examination. In the second phase eight CL sessions were performed with a group consisting of an average of fifteen people from the renal replacement therapy sector and the sectors that started to interact after the patients' hospitalization. Results: The analysis of the current activity demonstrated that patients with kidney problems continue arriving at the hospital through several routes and the hospital do not have the autonomy to deny the patient due to lack of space. The team absorbs this demand and suffers the initial impact is that it addresses acute renal failure (ARF) and team of nephrologists. Historical data demonstrate that the team remained the same while the number of patients tripled. Locations were set up for these patients to be dialyzed, occupying another sector, the Intensive Care Center (ICC), also with its full capacity. These changes led to secondary contradictions in the system of activity that emerged during CL sessions. The sessions provided a moment to discuss these problems and the change of some components of the group to a more systemic view of the situation and with the formation of agency on part of those involved. After the phases of questioning and historical construction of the activity, a proposal for a new model was developed that is more focused on the peritoneal dialysis method, that gives more autonomy for the patient, who can perform dialysis at home. Prevention was also on the focus of the discussion. Conclusion: The Change Laboratory Method provided the change in the understanding of the problems experienced by the hemodialysis sector in a personal to a systemic way. It also enabled micro cycles of expansive learning, but differently in different actors. There was the creation of agencies manifested in the sessions and also outside of them. CL has been shown to be an important method for building collective organizational changes.
ABSTRACT Introduction: Chronic kidney disease is a global public health problem and the tendency seems to increase. When renal capacity reaches parameters between 10 and 15%, renal replacement therapy is necessary. At the hospital in this study, the hemodialysis center has its full capacity installed and the demand for vacancies continues. The patients then began to be hospitalized waiting for the outpatient vacancy for periods that can reach 3 months. The hospitalization option, which seemed to work well in the beginning, soon created new interactions that did not exist before, as well as consequences for the patients, such as hospital infection and depression. Objective: To contribute to the implementation of new collaborative methodologies in the search for collective solutions of organizational determinants in health activities. Method: It was applied the Change Laboratory (CL) Method based on cultural historical theory and the principle of double stimulation that aims the collective construction of solutions. The study was divided in two phases: one of ethnographic data collection, with individual and collective interviews, on-site observation and documents examination. In the second phase eight CL sessions were performed with a group consisting of an average of fifteen people from the renal replacement therapy sector and the sectors that started to interact after the patients' hospitalization. Results: The analysis of the current activity demonstrated that patients with kidney problems continue arriving at the hospital through several routes and the hospital do not have the autonomy to deny the patient due to lack of space. The team absorbs this demand and suffers the initial impact is that it addresses acute renal failure (ARF) and team of nephrologists. Historical data demonstrate that the team remained the same while the number of patients tripled. Locations were set up for these patients to be dialyzed, occupying another sector, the Intensive Care Center (ICC), also with its full capacity. These changes led to secondary contradictions in the system of activity that emerged during CL sessions. The sessions provided a moment to discuss these problems and the change of some components of the group to a more systemic view of the situation and with the formation of agency on part of those involved. After the phases of questioning and historical construction of the activity, a proposal for a new model was developed that is more focused on the peritoneal dialysis method, that gives more autonomy for the patient, who can perform dialysis at home. Prevention was also on the focus of the discussion. Conclusion: The Change Laboratory Method provided the change in the understanding of the problems experienced by the hemodialysis sector in a personal to a systemic way. It also enabled micro cycles of expansive learning, but differently in different actors. There was the creation of agencies manifested in the sessions and also outside of them. CL has been shown to be an important method for building collective organizational changes.
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Palavras-chave
hemodiálise, atenção terciária à saúde, insuficiência renal crônica, hemodialysis, tertiary healthcare, chronic kidney disease