To evaluate the implementation of a telephone system in a department of Primary Care in Barcelona, Spain, supporting health professionals confined by COVID-19. We conducted an observational, descriptive, cross-sectional study with confined professionals, between March 11 and May 31, 2020. We emailed a questionnaire with 18 closed-ended questions and one open-ended question and performed a descriptive analysis of the closed-ended answers and an analysis of the thematic content of the open-ended question. Thirty-nine hundred and ninety-eight professionals evaluated the system overall with a score of 6.54 on a scale of 1 to 10. The evaluation of the format of calls made in the support system had higher scores, while the psychological support unit and the coordination of the different groups had lower scores. The content analysis of the open-ended question provides explanatory arguments for the quantitative results. The study allowed a valid and reliable evaluation of the implementation of a support system for confined professionals, in addition to recognizing areas for improvement. According to the World Health Organization (WHO), data from many countries indicate that the number of SARS-CoV-2 infections among healthcare workers is much higher than among the general population, and thousands of healthcare workers infected with SARS-CoV-2 have lost their lives worldwideRed Nacional de Vigilancia Epidemiológica) on May 21, 2020, reported 40,921 cases of COVID-193. Subsequent reports on the overall situation in the country show that the disease in healthcare professionals has continued to appear, with 82,690 cases reported as of July 14, 20214. However, seroprevalence data point to higher prevalences in healthcare personnel: 10.3% of a sample of primary care and hospital professionals in the northern metropolitan region of Barcelona were positive for anti-SARS-CoV-2 IgG, with no differences observed between primary care and hospital personnel5.The latest report on healthcare professionals in Spain, published by the National Epidemiological Surveillance Network  –healthcare area that provides service to 1,448,812 citizens from 70 municipalities in the province of Barcelona, and which has a staff of more than 4,500 professionals– launched a telephone service system to all professionals who were prescribed a home confinement between the February 17 and May 31, 2020, the period corresponding to the first wave of the epidemic.9.Considering the information available at that time on the evolution of the disease, the system was provided with a “biopsychosocial” orientation, since it intended to follow-up the clinical evolution of the professionals who presented symptoms at some point in the follow-up, in addition to offering recommendations and support in psychosocial issues related to the circumstances of the isolation, whether symptoms had developed or if the isolation was due to contact with positive patients. The follow-up team was interdisciplinary, made up of 16 nursing professionals, 5 family medicine professionals, 1 psychiatrist, 5 psychologists, and 1 professional from social work, under the administration of the Prevention Unit, responsible for Occupational Health of the organization. The follow-up consisted of telephone calls to follow-up the progress of the symptoms, assessment and response to psychosocial needs that may appear. The follow-up team met weekly to guarantee criteria for action and management of specific cases. The periodicity determined for making the calls was 72 hours, although it was a decision of the professionals to increase the time of calls, with a total of 10,419. The descriptive analysis of the sociodemographic and clinical characteristics of the professionals assisted in this support system was published recentlyThe objective of this research was to know how the professionals who had contact with positive patients or who manifested symptoms of COVID-19 evaluated both the care received and the functioning of the biopsychosocial system, as well as identify the needs perceived as poorly attended, with a view to implementing improvements in the system, in case of future needs.Observational, descriptive and transversal study, carried out with the workers of the administration of Primary Care of the North Metropolitan, in Barcelona, Spain. Inclusion criteria were to have confined at home by symptomatology or contact with COVID-19 between March 11 and May 31, 2020, and to have provided at least one contact email during the period of confinement. We did not define any exclusion criteria and we invited 1,247 professionals who met the inclusion criteria to participate, 398 responded our inviting, representing a response rate of 32%.Instituto Catalán de la Salud), a department that provides professional and logistical support to organize research initiatives that may arise in the territory. We distributed a questionnaire by e-mail through a survey management platform  with 6 expert judges was greater than 0.78 for all items. Cronbach’s α for the closed-response items was 0.93.We ensured the validity of the questionnaire using a procedure giving specific instructions to 6 expert judges asked to evaluate the Interpretability, Representativeness, Relevance of the items, by scoring from 1 to 4 for each item, after previous information about the purpose of the questionnaire. We also encouraged experts to share comments on writing of items and response options, suggestions for revisions, number and order of items, instructional text, missing items, headlines and layoutWe performed a descriptive analysis of the quantitative data presenting the categorical variables with frequency distribution, and the quantitative variables with mean, standard deviation, mode and median. We used Student’s t-test and ANOVA for the comparison of means, and any value of p < 0.05 was considered significant. We used the SPSS package, version 25.13. We conducted the quantitative and qualitative analyses in a sequential and explanatory manner, orienting the qualitative analysis to understanding of the quantitative results.Using the ATLAS.ti 8.4 program, the answers to the open-ended questions were subjected to a summative thematic content analysis, which involves coding and counting the answers based on a pre-established matrix of codes and interpreting the latent meaning of this content based on the contexts of use and co-occurrences of the codesThe first question of the questionnaire involved informed consent, if the participant accepted it, it was possible to continue the survey. All participants were volunteers, with anonymity guaranteed by deactivating the possibility of tracking answers, and no request for data that could reveal the participant’s identity. The Clinical Research Ethics Committee of IDIAPJGol (Code 20/209-PCV) approved the study.We sent the survey link to 1,247 people, of whom 398 initiated the survey. In the first question, 60 participants answered that they did not recall receiving the evaluated support, so the survey directed them to the open-ended comments and suggestions question, and 22 of them wrote comments on it. Of the remaining 338 participants who did recall receiving telephone support, 286 completed the entire survey.The sample was predominantly female (81.8%). The mean age was 47 years with a standard deviation of 10.4, minimum age 22 years and maximum age 65 years. Other sociodemographic characteristics are in Nurses and physicians were up to 63% of those responding the questionnaire and other groups of professionals were the rest of the sample. The mean overall score for the system was 6.54, with the worst possible score being 0 and the best possible score being 10. The mode was 8, and the median was 7. We performed a T test to compare the overall mean obtained according to gender, relevance to a vulnerable group, cohabitation with vulnerable persons, having children or not, PCR result, being a health sciences professional or not, and origin of infection. We did not find significant differences in any of the cases. We analyzed in more detail the result obtained in the evaluation by the psychological support unit, since it obtained a very low score. We performed bivariate analyses with all sociodemographic and occupational variables, finding no significant association.A total of 109 people (27.4%) answered the question “If you have any suggestions for improvement or comments, you can write them here” formulated to all participants.Analysis of the manifest content of the answers, coded according to the three dimensions of the bio-psycho-social approach, showed that most of the comments (n = 61) referred to organizational aspects , followed by those referring to psychological issues  and, finally, to issues related to symptom management .Despite the deductive approach of the analysis, categorizing the data in the three dimensions of the biopsychosocial orientation, the analysis of the context in which the comments were made and their co-occurrences showed how comments referring to the more psychological experience (“I felt very lonely”) and to the biological process of the disease (“I had a fever for 11 days”) were linked to explanations of concrete actions or omissions at the level of the socio-organizational management of the situation (“to demand the performance of the PCR”):During my illness I felt very lonely, I had to call to request a PCR, both at the beginning of my illness and in the pre-incorporation period. I had a fever for 11 days and did not receive a follow-up call, I was the one who decided to have a Chest X-ray, manage it, check it and see that there was pneumonia, talk to an internist, who prescribed medication. I did not feel supported at any time. I would not want to repeat an experience like this again. (43:2)As in this comment, the professionals located their experience of isolation in one place or another on the accompaniment-loneliness continuum as the effect of a combination of various concrete practices, often linked to the resolution of formal aspects, which may or may not have taken place during follow-up .In the first part of the process, my perception was of total abandonment, including the lack of PCR, until I was admitted to the hospital with pneumonia 15 days after the beginning of my confinement. After discharge, yes, I was very comforted by the calls from Dr. M.. She was very supportive psychologically and emotionally. I am very grateful to her. To the UPR, I give it a zero. (88:3)This commentary shows the link between the perception of loneliness and some of the weaknesses of the system, especially at the beginning . However, this loneliness is made up for the role of the psychological support. Dr. M” belongs to the Psychological Support Unit, activated in specific cases. There are few explicit references to “psychological support” (n = 5) in the set of open-ended responses and all, except this expression of gratitude, they are explicit requests to expand or integrate (n = 4) this type of service.Therefore, it is pertinent to make a distinction between the assessments of the psychological support unit and the perception of feeling emotionally accompanied as a result of received care in the framework of this follow-up system.As noted above, the value of the system as “emotional support” cannot be attributed exclusively to the performance of the Psychological Support Unit, but seems to emerge rather as the effect of a combination of various concrete practices that did or did not take place during follow-up, including those related to symptom management and “self-management of the disease” as detailed in the following quote.I consider the follow-up as essential, because of the support on the symptoms and uncertainties, especially at the beginning of the pandemic, when I was infected. About my process, I would also highlight the emotional support I received, I did not expect it and I found it and I was grateful for it. We are “patients” but at the same time health professionals, something that helps to self-manage the disease but, at the same time, to make some anticipations. (106:4)14. The intervention implemented would be along the lines of a Walkround, a common practice associated with patient safety, in which feedback is a powerful intervention15.Process and outcome indicators of healthcare services play a crucial role in patient satisfactionThis research highlights the responsiveness of the healthcare system to a crisis caused by the COVID-19 pandemic that placed the healthcare system in a situation of unprecedented stress, and which had to give a response to healthcare professionals in their role as patients. The professionals affected evaluated the response as satisfactory, giving the intervention an overall score of 6.54.9.We designed the evaluation meticulously to ensure that the questions did not contain interpretation biases and that the contents were those really intended to be evaluated. The analysis of the data, with no predictor variable for the results, shows that the participants responded to the questionnaire leaving aside the social and emotional situations that could affect them. Finally, the characteristics of the participants were very similar to those of the total number of confined professionals, as shown by the mean age of 47 years  and the high percentage of women, 81.8% The formal aspects of the calls had positive evaluation, with a high categorization of the responses.The biopsychosocial vocation is an important, and achieved, aspect in the implementation of the system, since the scores in the “usefulness of the calls” section are on a high position. The qualitative results show that there are different conceptions of the usefulness that this type of follow-up should have and that the system loses its value when there is no appreciation of this triple aspect.16. On the other hand, health professionals may not accept a more clinically focused system very well, assuming that they have a certain expertise in this field. Similarly, strictly psychological follow-up would cause rejection in a group where, paradoxically, occur a considerable stigmatization of mental health problems17. It is important to consider that the literature shows a considerable proportion of healthcare workers having experienced sleep and mood disorders during the pandemic18. Moral damage and the development of mental illness are real risks when working in unprecedented scenarios such as this one. Then, this study emphasizes we must work proactively to prevent the psychological consequences of the pandemic on healthcare workers from becoming severe19.Many hypotheses can explain this effect in light of the results and related literature. For example, if the preponderance is on the labor aspects, the perception may be balanced towards an intervention of pressure and control of human resources, and not of supportThe evaluation of the different groups participating in the system showed heterogeneous scores, including the very low score for the Psychological Support Unit, for which the quantitative analysis was unable to find any predictors to explain it. However, the results of the analysis of the open-ended responses allow us to develop some plausible explanations. On the one hand, the work of the Psychological Support Unit does not receive a negative evaluation, but critics for not having more presence. Data show clearly that the perception of emotional support or accompaniment goes beyond the work of this Unit and emerges as a result of a sum of small actions, often linked to management, information and coordination, facilitating personalized and more empathetic attention.The score obtained for the coordination of the different groups involved is lower than the midpoint. As expressed in the participants’ comments, the situation makes them tolerant towards this lack of coordination and the difficulty of implementing any initiative, which may result in benevolent scores.20.The evidence obtained allows the elaboration of an explanation that turns the unknown into the known, built from a process focused on options, experience and errors, areas that intervene in the process of problem recognition in its early stages of development, the first principle of high reliability organizations21. An intervention based on mobile devices was implemented in Spain, aimed at preventing and mitigating the most common problems in this situation22. The results of this specific evaluation did not show a significant impact of the intervention, so it is particularly relevant to complement this type of evidence with the assessments made by the target groups.Given the evidence of possible mental health effects on health professionals during the pandemic, various institutions and organizations have implemented strategies to address these types of problemsThere are some limitations in this study due to the low response rate, and although the reasons for the non-participation of the rest of the people invited to participate are unknown, the time lapse between the confinement period and the conclusion of the research may explain this. However, the heterogeneity of the sample characteristics and of the open-ended question comments do not suggest a selection bias.In conclusion, we evaluated the implementation of a biopsychosocial support system for primary care health professionals affected by COVID-19 applied in the early stages of the pandemic. The professionals have perceived the system as useful, since the number of scores is in the high range of the scale; however, they recognize some aspects needing improvement. There was variability in the responses which was due to the different expectations of professionals, the different adaptations that occurred as knowledge about the virus increased, and the understanding of the difficulty of the scenario where they were all working. 1.La COVID-19 es una enfermedad emergente que, el 18 de marzo de 2021, ha afectado globalmente a 120 millones de personas y ya ha causado 2,6 millones de muertes desde el inicio de la pandemia2.Los trabajadores sanitarios constituyeron la primera línea de respuesta al brote y, por lo tanto, estuvieron expuestos tanto ellos como sus familias a un riesgo sin precedentes. De acuerdo con la Organización Mundial de la Salud (OMS), los datos de muchos países indican que el número de infecciones por el SARS-CoV-2 entre los trabajadores de la salud es mucho mayor que entre la población general y miles de trabajadores sanitarios infectados por este virus han perdido la vida en todo el mundo3. Los informes posteriores sobre la situación general en el país muestran que la enfermedad en personal sanitario ha seguido apareciendo, habiéndose notificado, el 14 de julio de 2021, 82.690 casos4. Sin embargo, los datos de seroprevalencia apuntan a prevalencias mayores en personal sanitario: un 10,3% de una muestra de profesionales de atención primaria y hospitalaria de la región Metropolitana norte de Barcelona fue positiva para anti-SARS-CoV-2 IgG, sin observarse diferencias entre el personal de primaria y el hospitalario5.El último informe sobre profesionales sanitarios en España, publicado por la Red Nacional de Vigilancia Epidemiológica el 21 de mayo de 2020, notificaba 40.921 casos de la COVID-196.Asimismo, tal y como mostró el brote de SARS-1 de 2003, los profesionales de la salud están expuestos no solo al virus, sino también a numerosos elementos estresantes, como, por ejemplo, elevadas cargas de trabajo, estrés, fatiga, agotamiento y estigma. A este conjunto de amenazas se añade el hecho de que el aislamiento doméstico de casos sospechosos de SARS-CoV-2 y sus contactos sea una de las principales intervenciones no farmacológicas para mitigar e incluso suprimir su expansión, constituyendo un elemento predictor de trastornos por estrés postraumáticoAnte la primera aparición de un contacto de un profesional sanitario con un paciente positivo en SARS-CoV-2 y la consiguiente prescripción de su aislamiento, la dirección de Atención Primaria del área sanitaria Metropolitana Nord de Barcelona (España) –área sanitaria que presta servicio a 1.448.812 ciudadanos de 70 municipios de la provincia de Barcelona, y que cuenta con una plantilla de más de 4.500 profesionales– puso en marcha un circuito de atención telefónica dirigido a todos los profesionales a los que les fue prescrito un confinamiento domiciliario entre el 17 de febrero y el 31 de mayo de 2020, período correspondiente a la primera ola de la epidemia.9.Considerando la información disponible en aquel momento sobre la evolución de la enfermedad, se dotó al circuito de una orientación “biopsicosocial”, ya que pretendía hacer un seguimiento de la evolución clínica de los profesionales que presentaban síntomas en algún momento del seguimiento, además de ofrecer recomendaciones y apoyo en cuestiones psicosociales relacionadas con las circunstancias del aislamiento, tanto si se habían desarrollado síntomas como si el aislamiento era por contacto con pacientes positivos. El equipo de seguimiento era interdisciplinar, formado por 16 profesionales de enfermería, 5 de medicina de familia, 1 de psiquiatría, 5 de psicología, y 1 de trabajo social, bajo la dirección de la Unidad de Prevención, responsable de la Salud Laboral de la organización. El seguimiento consistió en llamadas telefónicas para seguimiento del avance de la sintomatología, valoración y respuesta a necesidades psicosociales que pudieran aparecer. El equipo de seguimiento se reunía semanalmente para garantizar criterios de actuación y gestión de casos particulares. La periodicidad que se determinó para la realización de las llamadas fue de 72 horas, aunque quedaba a criterio de los profesionales aumentar la cadencia de llamadas, siendo contabilizadas un total de 10.419. El análisis descriptivo de las características sociodemográficas y clínicas de los profesionales atendidos en este circuito de apoyo se ha publicado recientementeAnte esto, el objetivo de esta investigación fue conocer cómo los profesionales que tuvieron contacto con pacientes positivos o que manifestaron síntomas de la COVID-19 evaluaron tanto la atención recibida como el funcionamiento del circuito biopsicosocial, así como identificar cuáles fueron las necesidades que se percibieron como deficientemente atendidas, para poder implementar mejoras en el circuito, en caso de que este volviera a ser necesario.Estudio observacional, descriptivo y transversal, realizado con los trabajadores de la Dirección de Atención Primaria Metropolitana Nord, en Barcelona, España. El criterio de inclusión fue haber sido confinado en domicilio por sintomatología o contacto con la COVID-19 entre el 11 de marzo y el 31 de mayo de 2020 y haber facilitado al menos un email de contacto durante el período de confinamiento. No se definió ningún criterio de exclusión. Se invitó a participar a los 1.247 profesionales que cumplían los criterios de inclusión, de los que respondieron 398, lo que supone una tasa de respuesta del 32%.Los datos fueron recogidos por la Unitat de Suport a la Recerca de la Metropolitana Nord del Instituto Catalán de la Salud (ICS), departamento que brinda apoyo profesional y logístico para organizar las iniciativas de investigación que puedan surgir en el territorio. Se distribuyó un cuestionario por correo electrónico a través de una plataforma de gestión de encuestas . Este cu10 para dotar de validez y fiabilidad los cuestionarios creados. La investigación se llevó a cabo a petición del Departamento de Calidad, por lo que el primer paso fue conocer qué temas se querían explorar. En segundo lugar, se decidió la metodología de recogida de datos más apropiada, por tratarse de cuantificación de medidas generales, y buscando la facilidad y rapidez para su cumplimentación se optó por un cuestionario de 17 preguntas con respuesta en escala numérica de 0 a 3, y una pregunta con respuesta de 1 a 10. Para ampliar los hallazgos se dio la posibilidad de expresarse en una pregunta abierta cuya respuesta se analizó con métodos cualitativos.Se elaboró un cuestionario ad hoc siguiendo las recomendaciones de Boynton y GreenhalghSe valoró como no recomendable la utilización de un instrumento de medida estandarizado por el contexto particular de pandemia que se vivió por primera vez en un ámbito sanitario determinado, para el cual cualquier cuestionario utilizado en otro contexto perdería su validez.11.En relación con la apariencia del cuestionario se cuidaron los detalles relativos a fuente y tamaño de la letra y longitud de las preguntas para asegurar una tasa de respuesta elevada. Además, se realizaron 5 entrevistas cognitivas pretest con una muestra de potenciales participantes en el estudio para que evaluaran una primera versión del cuestionario mediante la técnica del think aloud12. El Índice de Validez de Contenido para los Ítems finales (I-IVC) de respuesta cerrada, con 6 jueces expertos fue superior a 0,78 en todos los ítems. El α de Cronbach para los elementos de respuesta cerrada fue de 0,93.Se aseguró la validez del cuestionario a través de un procedimiento en el que se dieron instrucciones específicas a 6 jueces expertos a los que se les pidió que evaluaran la Interpretabilidad, Representatividad, Relevancia de los ítems puntuando de 1 a 4 cada uno de ellos, previa información sobre el propósito del cuestionario. También se alentó a los expertos a compartir comentarios sobre la redacción de los elementos y las opciones de respuesta, sugerencias de revisión, número y orden de los elementos, textos de instrucciones, elementos faltantes, titulares y diseñoSe realizó un análisis descriptivo de los datos cuantitativos que presentan las variables categóricas con distribución de frecuencias, y las variables cuantitativas con media, desviación estándar, moda y mediana. Para la comparación de medias se utilizó la prueba t de Student y ANOVA, y se consideró significativo todo valor de p < 0,05. Se utilizó el paquete SPSS, versión 25.13. Los análisis cuantitativo y cualitativo se llevaron a cabo de manera secuencial y explicativa, orientando el análisis cualitativo a la comprensión de los resultados cuantitativos.Mediante el programa ATLAS.ti 8.4, las respuestas a las preguntas abiertas se sometieron a un análisis de contenido temático sumativo, que involucra la codificación y el conteo de las respuestas con base en una matriz de códigos preestablecida e interpretación del significado latente de este contenido a partir de los contextos de uso y coocurrencias de los códigosLa primera pregunta del cuestionario estuvo relacionada con el consentimiento informado, y si el participante lo aceptaba, podría continuar la encuesta. La participación fue voluntaria y se garantizó el anonimato desactivando la posibilidad de seguimiento de las respuestas, además de no solicitar datos que permitieran conocer la identidad del participante. El estudio fue aprobado por el Comité de Ética de Investigación Clínica del IDIAPJGol (Código 20/209-PCV).El enlace de la encuesta se envió a 1.247 personas, de las cuales 398 iniciaron la encuesta. En la primera pregunta 60 participantes contestaron no recordar haber recibido el apoyo que se estaba evaluando, por lo que la encuesta les dirigió a la pregunta abierta de comentarios y sugerencias, y 22 de ellos escribieron comentarios en ella. De los 338 participantes restantes que sí recordaban haber recibido el apoyo telefónico, 286 finalizaron la encuesta completa.La muestra tuvo mayor predominio femenino . La edad media fue de 47 años con una desviación estándar de 10,4, la edad mínima 22 años y la máxima 65. Otras características sociodemográficas se describen en la El cuestionario fue contestado por enfermeras y médicos en el 63% y el resto por diferentes colectivos profesionales. La La puntuación global media que obtuvo el circuito fue un 6,54, siendo la peor puntuación posible el 0 y la mejor posible un 10. La moda se situó en el valor 8, y la mediana en el 7. La Se realizó T test para comparar la media global obtenida según género, pertinencia a un grupo vulnerable, convivencia con personas vulnerables, tener hijos o no, resultado de la PCR, ser profesional de ciencias de la salud o no, y origen del contagio. No se encontraron diferencias significativas en ninguno de los casos. La Se analizó con más detalle el resultado obtenido en la evaluación por la unidad de apoyo psicológico, ya que obtuvo una puntuación muy baja. Se realizaron análisis bivariados con todas las variables sociodemográficas y laborales, no encontrando ninguna asociación significativa.Un total de 109 personas  respondieron a la pregunta “Si tiene alguna sugerencia de mejora o comentario, lo puede escribir aquí” que se formuló a todos los participantes.El análisis del contenido manifiesto de las respuestas, codificadas a partir de las tres dimensiones del enfoque bio-psico-social, mostró que la mayoría de los comentarios (n = 61) hicieron referencia a aspectos organizativos , seguidos de aquellos referidos a cuestiones psicológicas  y, finalmente, a temas relativos al manejo de síntomas .A pesar del enfoque deductivo del análisis, categorizando los datos en las tres dimensiones de la orientación biopsicosocial, el análisis del contexto en el que se hacían los comentarios y sus coocurrencias mostró cómo se entrelazaban comentarios referidos a la vivencia más psicológica (“me sentí muy sola”) y del proceso biológico de la enfermedad (“estuve 11 días con fiebre”), con explicaciones de acciones u omisiones concretas a nivel de la gestión socio-organizativa de la situación :Durante mi enfermedad me sentí muy sola, tuve que llamar yo para reclamar la realización de la PCR, tanto al inicio del cuadro como la de preincorporación. Estuve 11 días con fiebre y no recibí ni una llamada de seguimiento, fui yo quien decidió hacerme una Rx de Tórax, gestionarla, revisarla y ver que había una pneumonía, hablar con un médico internista, quien me prescribió medicación. No me sentí apoyada en ningún momento. Me gustaría que no se volviera a repetir una vivencia como esta. (43:2)Como en este comentario, los profesionales ubicaban su experiencia del aislamiento en un lugar u otro del continuo acompañamiento-soledad como efecto de una combinación de diversas prácticas concretas, vinculadas muchas veces a la resolución de aspectos formales, que tuvieron lugar o no durante el seguimiento .En la primera parte del proceso vivido, mi percepción fue de abandono total y la no realización de PCR hasta que ingresé en el hospital con una pneumonía después de 15 días de iniciar mi confinamiento. Una vez dado de alta, sí, me sentí muy reconfortado por las llamadas de la Dra. M. Me sirvió mucho de apoyo psicológico y emocional. Le estoy muy agradecido. A la UPR, un cero. (88:3)En este extracto se constata la vinculación entre la percepción de soledad y algunas de las fragilidades del circuito, especialmente en su inicio . Sin embargo, también se contrapone a esta soledad el papel del apoyo psicológico. La “Dra. M” pertenece a la Unidad de Apoyo Psicológico, que se activaba en casos puntuales. Hay pocas referencias explícitas al “apoyo psicológico” (n = 5) en el conjunto de respuestas abiertas y todas, excepto esta muestra de agradecimiento, son peticiones expresas de ampliar o integrar (n = 4) este tipo de servicio.Por consiguiente, parece pertinente establecer una distinción entre las valoraciones de la unidad de apoyo psicológico y la percepción de sentirse acompañada emocionalmente como consecuencia de ser atendido en el marco de este circuito de seguimiento.Tal y como se apunta más arriba, el valor del circuito en tanto “apoyo emocional” no se puede atribuir exclusivamente al desempeño de la Unidad de Apoyo Psicológico, sino parece emerger más bien como efecto de una combinación de diversas prácticas concretas que tuvieron lugar o no durante el seguimiento, incluyendo aquellas referidas al manejo de síntomas y “autocontrol de la enfermedad” como se detalla en el siguiente extracto.Valoro imprescindible el acompañamiento, por el soporte sobre los síntomas y las incertidumbres, sobretodo al principio de la pandemia, que es cuando yo me infecté. De mi proceso, además, destacaría el apoyo emocional recibido, no lo esperaba y lo encontré y lo agradecí. Somos “pacientes” pero a la vez profesionales de la salud, hecho que ayuda al autocontrol de la enfermedad pero, a la vez, también a anticiparse. (106:4)14. En esta línea, la intervención implementada estaría en la línea de un Walkround, práctica común asociada con la seguridad del paciente, en que la retroalimentación es una intervención potente15.Los indicadores de proceso y resultado de los servicios sanitarios tienen un papel crucial en la satisfacción de los pacientesEsta investigación pone de manifiesto la capacidad de respuesta del sistema sanitario ante una crisis provocada por la pandemia de la COVID-19 que colocó al sistema sanitario en una situación de estrés sin precedentes, y que se tuvo que dar respuesta a los profesionales sanitarios en su rol de pacientes. Los profesionales afectados valoraron la respuesta como satisfactoria al puntuar la intervención de manera global con un 6.54.9.La evaluación realizada se diseñó meticulosamente asegurando que las preguntas no contuvieran sesgos de interpretación y que los contenidos fueran los que realmente se pretendieron evaluar. El análisis de los datos, en el que ninguna variable fue predictora de los resultados, pone de manifiesto que los participantes respondieron al cuestionario dejando de lado las situaciones sociales y emocionales que les pudieran afectar. Por último, las características de los participantes fueron muy similares a las del total de confinados, como muestran los resultados de edad media de 47 años  y el elevado porcentaje de mujeres el 81,8% Los aspectos formales de las llamadas fueron evaluados de manera positiva, situándose en la parte alta una categorización de las respuestas.Un aspecto importante en la implementación del circuito fue su vocación biopsicosocial, que se puede evaluar como conseguida, ya que las puntuaciones de la sección “utilidad de las llamadas” se encuentran en la parte alta. Los resultados cualitativos demuestran que, en efecto, existen diferentes concepciones de la utilidad que este tipo de seguimiento debe tener y que, cuando no se aprecia esta triple vertiente, el circuito pierde valor.16. Por otro lado, un circuito demasiado centrado en los aspectos clínicos puede no ser bien recibido por profesionales sanitarios a los que se les supone un cierto bagaje en este campo. Por último, de manera análoga, un seguimiento estrictamente psicológico puede ser rechazado por un colectivo en el que, paradójicamente, existe una considerable estigmatización de los problemas de salud mental17. Considerando que la literatura evidencia que una proporción considerable de trabajadores sanitarios han experimentado trastornos del sueño y del estado de ánimo durante la pandemia18, que los daños morales y el desarrollo de enfermedades mentales son riesgos reales cuando se trabaja en escenarios sin precedentes como este, el presente estudio incide en que se deberá trabajar de manera proactiva para evitar que las consecuencias psicológicas de la pandemia en el personal sanitario sean dramáticas19.Se pueden plantear diferentes hipótesis para explicar este efecto a la luz de los resultados y la literatura relacionada. Por ejemplo, si la preponderancia se encuentra en los aspectos laborales, se puede balancear la percepción hacia una intervención de presión y control de recursos humanos, y no de apoyoLa evaluación de los diferentes colectivos que participaron en el circuito arrojó puntuaciones heterogéneas, y entre ellas destacó la muy baja puntuación que obtuvo la Unidad de Apoyo Psicológico del que el análisis cuantitativo no pudo encontrar predictores que lo explicaran. Sin embargo, los resultados del análisis de las respuestas abiertas permiten elaborar algunas explicaciones plausibles. Por un lado, el trabajo de la Unidad de Apoyo Psicológico no se valora negativamente, sino más bien se critica que no tuviera más presencia. Además, se desprende de los datos que la percepción de apoyo o acompañamiento emocional va más allá del trabajo de esta Unidad y emerge como resultado de una suma de pequeñas acciones, muchas veces vinculadas con la gestión, la información y la coordinación, facilitando una atención personalizada y más empática.En este sentido, la puntuación obtenida en la coordinación de los diferentes colectivos implicados se encuentra por debajo del punto medio. Además, tal y como expresan los comentarios de los participantes, la situación sobrevenida les hace ser comprensivos hacia esta falta de coordinación y la dificultad de la implementación de cualquier iniciativa, lo cual les puede haber hecho ser benevolentes en sus puntuaciones.20.Las evidencias obtenidas permiten elaborar una explicación que convierte lo desconocido en conocido, construida a partir de un proceso enfocado en opciones, experiencia y errores, áreas que intervienen en el proceso de reconocimiento de problemas en sus primeras etapas de desarrollo, el primer principio de las organizaciones de alta fiabilidad21. En España, se implementó y evaluó la eficacia de una intervención basada en dispositivos móviles orientada a prevenir y mitigar los problemas de salud mental más comunes en esta situación22. Los resultados de esta evaluación en concreto no mostraron un impacto significativo de la intervención, por lo que resulta especialmente pertinente complementar este tipo de evidencia con las valoraciones que hacen los colectivos a las que van dirigidas.Ante la evidencia de posibles afectaciones a la salud mental de los profesionales sanitarios durante la pandemia, diversas instituciones y organismos pusieron en marcha estrategias para abordar este tipo de problemáticasExisten algunas limitaciones en este estudio debido a la baja tasa de respuesta, y aunque se desconocen los motivos para la no participación del resto de las personas invitadas a participar, lo que podría explicarse por el lapso de tiempo entre el período de confinamiento y la realización de la encuesta. Sin embargo, la heterogeneidad de las características de la muestra y de los comentarios de la pregunta abierta no parecen mostrar un sesgo de selección.En conclusión, se ha evaluado la implementación de un circuito biopsicosocial de apoyo a profesionales sanitarios de atención primaria afectados por la COVID-19 que se puso en marcha en los primeros momentos de la pandemia. Los profesionales han percibido el circuito como útil, ya que el valor número de puntuaciones se encuentra en los valores altos de la escala, sin embargo, se reconocen algunos aspectos de mejora. Se ha encontrado variabilidad en las respuestas derivada de las diferentes expectativas que pueden tener los profesionales por las diferentes adaptaciones que se fueron llevando a cabo a medida que aumentaba el conocimiento del virus y por la comprensión de la dificultad del escenario en el que se estaba trabajando.


Assim, de acordo com diretrizes aceitas,9, apresenta dados oriundos de hemocentros no Estado do Ceará relativos a sorologia para DC ao longo de extenso período temporal e reaviva a evidência suscitada por algumas reflexões inquietantes:10O estudo publicadoleishmania spp, também endêmica na região, e que poderia ser responsável, pelo menos em parte, por resultados tão intrigantes.11 Mas é importante, desde já, enfatizar que pelo relato dos Autores, a inconclusividade inicial foi decorrente de um único teste ELISA que não seria nem positivo nem negativo. Isso é diferente de inconclusividade decorrente de dois testes sendo um positivo e outro negativo, situação reconhecida habitualmente em diretrizes.Considerando ser essa região endêmica, com transmissão vetorial ainda ativa pelo próprio relato dos Autores, chama atenção o elevado número de exames inconclusivos (70%) nos considerados doadores inelegíveis, e levantando a possibilidade de reação cruzada comCaracteristicamente no trabalho em pauta, a repetição do mesmo teste baseado em ELISA em segunda coleta mostrou que de 1.225 testes positivos ou inconclusivos pelo primeiro teste, em apenas 425 pacientes os resultados persistiam positivos ou inconclusivos. Isso sugere baixa reprodutibilidade, algo preocupante, e indiretamente corroborado pelo relato de que 43% dos excluídos no primeiro exame já haviam sido doadores. Assim, a negatividade no exame de triagem da doação anterior teria levado a potencial recepção de material oriundo de paciente “falso-negativo” para doença de Chagas.Western blot), verificou-se que 305 foram negativos, 48 inconclusivos, e apenas 72 persistiram com testes positivos com base no terceiro exame sorológico.Ainda, destes 425 pacientes dentre os 1.225 com resultados positivos (333) ou inconclusivos (92) persistindo após os dois primeiros testes baseados em ELISA na primeira e segunda amostras, foram escrutinizados outra vez nesta segunda amostra sanguínea com nova sorologia, desta feita com diferente método sorológico  de 24 casos que receberam transfusão contaminada, tendo um caso desenvolvido sinais clínicos de miocardite na fase aguda.A caracterização pela Organização Mundial da Saúde da DC como “negligenciada” adquire certamente mais força com a constatação de que, 50 anos após o estabelecimento de testes obrigatórios para doadores em nosso meio, ainda se verifica o descarte de bolsas por conta do elevado número de testes inconclusivos. Os impactos sociais e financeiros desta “inconsistência” sorológica estão para serem determinados.15 Além disso, mesmo o algoritmo sucessivo  para comprovação diagnóstica16 parece desafiado por evidências como as agora publicadas nos ABC por pesquisadores do Ceará.De toda forma, essas duas vertentes do dilema imposto pela incerteza são imanentes ao contexto de situações enigmáticas envolvendo diagnóstico quando inexiste padrão-ouro, e a acurácia de todo teste empregado no “mundo-real” vá ser aferida em ambiente amostral diverso daquele em que o teste foi padronizado. Assim, persiste por se comprovar cabalmente a correção da suficiência de apenas um teste negativo de alta sensibilidade para excluir a DC. 1In a series of 65 patients evaluated between 07/01/2011 and 12/31/2012 by invasive coronary angiography to elucidate the cardinal symptom of chest pain, all with wall motion abnormalities , two distinct serological tests were positive in only 11(17%) patients.2How can we elucidate this enigma and provide guidance in this situation? The answer may be, in part, in the experience with this entity and in the knowledge and confidence in the diagnostic accuracy of the serological tests employed.Cardiologists and Gastroenterologists acting in distinct environments of our institution in Ribeirão Preto, not infrequently face patients with epidemiologic, clinical and laboratorial features of Chagas Disease (CD) in whom serological evaluation is negative for the disease.4only one negative test is enough to exclude the diagnosis (granting blood donation or solid organ transplantation), while two distinct positive serological tests are needed to confirm CD diagnosis. This is an ancient practice in clinical and research routines, due to the heterogeneous accuracy (mean of sensibility and specificity) of the tests/ e. g. complement fixation, indirect hemagglutination, indirect immunofluorescence and direct agglutination).5Even after the development of chemiluminescence methods based on ELISA, capable of automated reading to avoid subjective interpretation as seen in the above-mentioned tests, the rule of two simultaneous distinct tests followed by a third one if a discordant result is obtained, remains in the latest PAHO guidelines for diagnosis of CD.6A conflicting technical note from the WHO recommended a single ELISA test for screening in blood banks, supported by its alleged high sensitivity (nearly 99%) and as a way of cost reduction when dealing with a high volume of screening as occurs in blood centers and blood banks.7Nevertheless, well-documented evidence exists suggesting that this protocol may not be entirely adequate.8The hitch point begins with the asymmetrical concepts leading to uncertainty that involve the routine diagnostic procedures of CD by using serological verification of antiparasite antibodies. In accordance to current guidelines,9presents data from blood centers in Ceará state related to CD serological tests in an extensive period and renew the evidence leading to some unsettling reflections:10The study published in this issue of Arquivos Brasileiros de Cardiologia,leishmania spp, also endemic in the region, that could be responsible, at least partially, for those so intriguing results.11It is relevant, from now on, to emphasize that from the Authors report, the initial inconclusive result was based in only one ELISA neither positive nor negative. This is distinct from an inconclusive result of two tests, one positive and other negative, a common finding in clinical guidelines.Since it is an endemic region with vectorial transmission still present by the Authors report, the strikingly high number of inconclusive tests (70%) in those donors considered ineligible, rises the possibility of a cross reaction withCharacteristically in the present paper, the repetition of the ELISA test in a second sample in 1,225 previously positive or inconclusive results, only in 425 samples remained positive or inconclusive. This result suggests low reproducibility, a concerning result reinforced by their report that 43% of those excluded in the first test had previously donated blood. This indicates that the negative result in the first screening test led to the potential acceptance of a CD false-negative donor.Western blot). In this third test, 305 were negative, 48 inconclusive and only 72 remained positive.Furthermore, those 425 donors with positive (333) or inconclusive (92) results after two ELISA tests in two distinct samples, had their second sample submitted to another serological test  of 24 recipients of one contaminated bag had only one case with clinical signs of the acute phase myocarditis.The definition by the World Health Organization of Chagas disease as “neglected” certainly acquires more strength by the recognition that 50 years after the establishment of mandatory tests in blood donors in our country, the number of discarded bags due to the number of inconclusive results is huge. Financial and social impact of this serological inconsistency are still to be established.15Besides, even a two-step algorithm (a positive high sensibility test followed by a high specificity one) to establish diagnosis16seems challenged by evidence now published by researches from the state of Ceará.Anyway, these two pathways of the dilemma imposed by uncertainty are immanent to the context of enigmatic situations involving diagnosis when no gold-standard exists and accuracy of every test applied to the “real-world” will be assessed in a diverse environment from the one it was standardized. Therefore, it rests to be properly established the sufficiency of only one high sensibility serological test to exclude CD.


De acordo com a Organização Mundial da Saúde, países emergentes terão um crescimento considerável no número de ataques cardíacos e mortes relacionadas. Um dos principais problemas médicos no Brasil é a mortalidade causada por infarto agudo do miocárdio com supra de ST (IAMCSST). A Sociedade de Cardiologia do Estado de São Paulo nunca treinou não-cardiologistas para atendimentos de emergência. Os pacientes normalmente buscam ajuda em prontos-socorros, em vez de chamar a ambulância. Nosso objetivo foi reduzir as taxas de mortalidade hospitalar causada por infarto agudo do miocárdio ao treinar profissionais da emergência na cidade de São Paulo. Utilizamos um programa de treinamento para as equipes de cinco hospitais com > 100 pacientes internados com IAMCSST por ano, e pelo menos 15% de mortes hospitalares relacionadas ao IAMCSST. Realizamos treinamentos online, organizamos de dois a quatro eventos para até 400 participantes, fizemos folders e panfletos informativos. A análise estatística utilizou o teste para comparação de duas proporções, com p <0,05. Quase 200 médicos e 350 enfermeiros participaram de pelo menos um treinamento de maio de 2010 até dezembro de 2013. Inicialmente, muitos médicos da emergência não reconheciam um infarto agudo do miocárdio no eletrocardiograma, mas a tele-ecocardiografia é usada em alguns departamentos da emergência para determinar o diagnóstico. A taxa de mortalidade nos cinco hospitais caiu de 25,6%, em 2009, para 18,2%, em 2010 . Depois da conclusão do período de treinamento, as mortes relacionadas ao IAMCSST em todos os hospitais públicos de São Paulo diminuíram de 14,31%, em 2009, para 11,25%, em 2014 . Mesmo programas simplificados de treinamento de pessoal da emergência pode reduzir muito as taxas de morte por infarto agudo do miocárdio em países em desenvolvimento. As autoridades públicas estimam que ≥ 70% da população utiliza esses serviços, desde a atenção primária até tratamentos especializados. A taxa de mortalidade hospitalar da cidade causada pelo IAMCSST em 2009 foi de 14,1%,5 quase duas vezes a porcentagem encontrada em países desenvolvidos. Naquela época, o tratamento disponível para IAMCSST na maioria dos hospitais de São Paulo era a terapia trombolítica com uso da estreptoquinase. Hoje, o sistema público de saúde tem 46 hospitais gerais, 139 unidades de emergência para atenção básica e 400 ambulatórios. Dos 46 hospitais gerais, somente seis podem realizar a intervenção coronária percutânea (ICP) primária, e não há um sistema organizado para transferir pacientes para esses hospitais para realizar a ICP, nem para submeter os pacientes à angiografia coronária imediatamente após a trombólise. A Sociedade de Cardiologia do Estado de São Paulo, que faz parte da Sociedade Brasileira de Cardiologia, pensou em aprimorar o cuidado dirigido a esses pacientes. A Sociedade tem treinado cardiologistas há muitos anos, mas os cardiologistas não são os profissionais que estão nos prontos-socorros; lá ficam os médicos internos e especialistas como ginecologistas e ortopedistas.Doenças cardiovasculares continuam sendo a principal causa de morte em muitos países. De acordo com a Organização Mundial da Saúde, países emergentes apresentarão um grande crescimento no número de ataques cardíacos e, consequentemente, no número de mortes.12 Considerando a relativa simplicidade do diagnóstico e do tratamento do IAMCSST, não está claro se o treinamento básico pode, de fato, reduzir as taxas de mortalidade. Dentre os hospitais públicos de São Paulo, somente aqueles com unidades especializadas de cardiologia podem realizar a ICP, e a mortalidade por IAMCSST é aceitável (6 a 7%) nesses hospitais. Alguns dos 24 hospitais que não oferecem tratamentos na área da cardiologia intervencionista tinham uma taxa de morte relacionada ao IAMCSST >15% em 2009, de acordo com dados da Secretaria de Saúde do Estado de São Paulo.13 A Sociedade de Cardiologia do Estado de São Paulo treina cardiologistas, inclusive para o diagnóstico e tratamento da IAMCSST, desde 1976, mas nunca treinou profissionais não-cardiologistas que atuam na emergência. Os moradores de São Paulo não costumam ligar para o 193  quando sentem dor aguda no peito; preferem ir ao pronto-socorro, unidades básicas de saúde e hospitais gerais da cidade. Assim, nosso objetivo foi o de reduzir a taxa de mortalidade hospitalar relacionada ao IAMCSST oferecendo um programa de treinamento para os profissionais da emergência  na cidade de São Paulo.Treinamentos, reforço dos treinamentos e revisão são ferramentas importantes para qualquer atualização na área médica, mas talvez não sejam necessários para conteúdos muito básicos. Outras iniciativas semelhantes trouxeram resultados esclarecedores em outros países.Depois de três reuniões com os chefes de unidades de emergência e departamentos de pronto-atendimento de hospitais, a Sociedade de Cardiologia, juntamente com a Secretaria de Saúde do Estado de São Paulo e a Secretaria de Saúde da cidade de São Paulo, desenvolveram um programa de treinamento.Nós pré-estabelecemos um primeiro objetivo: ensinar os profissionais dos cinco hospitais que tiveram mais de 100 pacientes com IAMCSST em um ano e taxa de mortalidade hospitalar relacionada ao IAMCSST ≥15%. Para esses cinco hospitais, realizamos treinamentos presenciais aos sábados. Durante os encontros, observamos que muitos participantes tinham medo de iniciar a terapia trombolítica.Além do treinamento presencial, usamos ferramentas virtuais para os treinamentos online, fizemos reuniões de atualização, como os simpósios para até 400 participantes de duas a quatro vezes por ano, criamos informativos virtuais e panfletos. As reuniões presenciais e os simpósios incluíram um programa de treinamento de quatro horas, com três seminários abordando o diagnóstico diferencial de dor no peito, dor torácica e diagnóstico e tratamento do infarto agudo do miocárdio (IAM) no departamento de emergência. Depois de cada treinamento, havia uma sessão de perguntas e respostas. Médicos, enfermeiros e outros profissionais da emergência foram convidados a participar.O principal objetivo foi avaliar os efeitos do treinamento nas taxas de mortalidade hospitalar relacionadas ao IAMCSST. Durante os três anos, a estreptoquinase foi substituída pela tenecteplase em alguns hospitais. Depois do tratamento com trombolíticos, aspirina, clopidogrel e enoxaparina, os pacientes foram transferidos para um hospital terciário capaz de fornecer tratamentos de cardiologia intervencionista e cirurgia. A incidência de IAM e sua taxa de mortalidade associada foi atualizada a cada semestre pela Secretaria de Saúde do Estado de São Paulo. Esta informação veio de hospitais públicos, que preencheram formulários sobre internação, alta e taxas de mortalidade hospitalar.Para avaliar a influência tanto do programa de treinamento como da estratégia da tecnecteplase seguida de transferência para um hospital de referência nas taxas de mortalidade, monitoramos especificamente um hospital que introduziu a tecnecteplase e avaliou as taxas de mortalidade quatro meses após o treinamento; depois, avaliou o início da estratégia da tecnecteplase ao longo dos anos, depois de 2013 até 2015. Além disso, avaliamos os mesmos dados de outros cinco hospitais com taxa de mortalidade associada ao IAMCSST ≥15% como controle. Um Conselho de Ética Institucional aprovou o estudo, cujos dados foram coletados da Secretaria de Saúde do Estado de São Paulo, Brasil.®, versão 4.02.9.14 Valor de p foi considerado significativo quando < 0,05.Obtivemos os dados para este estudo da Secretaria de Saúde da cidade de São Paulo. A base de dados continha informações de cada unidade de saúde onde um paciente tenha sido admitido, gerando uma autorização para internação. Utilizamos o número de mortes (N) e as taxas de mortalidade (%) para realizar o teste para comparação de duas proporções, usando o software Primer of Biostatistics Oferecemos treinamento presencial para profissionais da emergência de cinco hospitais, e estendemos o treinamento a três outros hospitais em 2010. Os mesmos participantes passaram por treinamento de reciclagem virtuais e simpósios de atualização. Doze unidades de emergência também treinaram suas equipes. Muitos outros hospitais treinaram seu pessoal de emergência e terapia intensiva de 2011 a 2013. No total, aproximadamente 200 médicos e 350 enfermeiros participaram de pelo menos uma sessão de treinamento de maio de 2010 até dezembro de 2013. Observamos que muitos médicos da emergência não conseguiram identificar um IAM no eletrocardiograma. Quase 50 departamentos de emergência usaram a tele-eletrocardiografia, que causa um atraso de cinco minutos no diagnóstico. Mesmo naqueles departamentos, a equipe de emergência costumava ter medo de iniciar a terapia trombolítica. As taxas de mortalidade associadas ao IAMCSST nos cinco hospitais pré-determinados (numerados de 1.a 5), com treinamento presencial, reduziram suas taxas de 25,9%, em 2009, para 18,3%, em 2010, com diferença significativa    . Os cinNo período dos três anos, o número de infartos do miocárdio diagnosticados aumentou em 12,61%. Porém, o número de mortes caiu em 177, uma redução absoluta de 3,06%, e uma redução de risco relativo de 21,39%.Dados do hospital monitorado mostram que: este hospital .5 Este número foi muito alto (14%) em comparação com dados dos Estados Unidos .13 O aumento absoluto no número de casos de IAM de 2010 a 2013 está de acordo com as projeções da Organização Mundial da Saúde,1 e deve crescer ainda mais nos próximos vinte anos. Neste estudo, o treinamento básico para equipes de emergência gerou uma redução significativa no número de mortes causadas por IAM (1.022 vs 905), com redução absoluta de 3,06%. Na verdade, o programa abordou duas grandes questões no programa de treinamento: dificuldade de interpretar um eletrocardiograma; e medo de prescrever a terapia trombolítica devido à possibilidade de sangramento cerebral. Sabemos que esses resultados devem ser mantidos, e consideramos que isso só será possível com um programa de treinamento contínuo direcionado a equipes da emergência. Reconhecemos a possibilidade de que a estratégia de tratar o IAM com tenecteplase, seguida da transferência para um hospital de referência, possa ter contribuído com a redução observada nas taxas de mortalidade. Porém, como tínhamos pré-estabelecido o monitoramento em um hospital, foi possível observar uma redução de mortalidade impressionante: de 23,7% para 13,9%, até antes do início da estratégia com tenecteplase e apenas quatro meses após o início do treinamento. Os hospitais que não tiveram o treinamento não demostraram diferenças neste período, e alguns deles apresentaram maiores taxas de mortalidade. Infelizmente, as taxas de mortalidade continuam a crescer entre pacientes com IAMCSST em nossa cidade, e os esforços para mudar este cenário deveriam considerar a estratégia de treinar equipes de emergência e apoiá-los por meio da tele-ecocardiografia e da telemedicina.A porcentagem de mortes causada por IAM ficou estável de 2002 a 2009.O estudo teve algumas limitações. Não foi possível obter todos os dados que gostaríamos, como número exato de profissionais treinados, número de profissionais que refizeram o treinamento, o início dos sintomas, os tempos de entrada do paciente e porta-balão, assim como tempo de porta-trombólise. Os dados são de alguns anos atrás, mas hoje em dia hospitais públicos que são similares a este do estudo ainda não possuem uma rotina de realiar a trombólise ou de imediatamente transferir esses pacientes para hospitais com capacidade de ICP.Concluímos que o treinamento de equipes de emergência reduziu de forma significativa as taxas de mortalidade e morbidade hospitalar causadas por IAM. A estratégia de implementar treinamento e reciclagem no treinamento de pessoal nos hospitais públicos pode salvar vidas. 1 In 2010, Brazil, which had 200 million inhabitants, had an estimated incidence of 116 heart attacks per 100,000 people,2 compared to 294 per 100,000 in the United States.3 The main medical issue in Brazil is mortality caused by ST elevation myocardial infarction (STEMI), which is no longer the case for developed countries.4 The biggest city in Brazil, the São Paulo metropolitan area, has nearly 18 million inhabitants, most of whom depend on the city’s public health system. Public authorities estimate that ≥70% of the population uses public health services, from primary care to specialized treatments. The city’s in-hospital mortality rate due to STEMI in 2009 was 14.1%,5 nearly twice as much as the percentage in developed countries. At that time, the available treatment for STEMI in most of the hospitals in São Paulo was thrombolytic therapy with streptokinase. Currently, the public health system has 46 general hospitals, 139 emergency units for basic emergency care, and 400 ambulatory units. Out of the 46 general hospitals, only 6 can provide primary percutaneous coronary intervention (PCI), and there is no organized system to transfer patients to these hospitals for PCI nor to submit patients to coronary angiography immediately after thrombolysis. The Society of Cardiology in the State of São Paulo, which is part of the Brazilian Society of Cardiology, thought to improve the care addressed to these patients. The Society has trained cardiologists for many years, but cardiologists are not in the emergency rooms; instead, internal medicine physicians and specialists such as gynecologists and orthopedists compose the staff of the emergency units.Cardiovascular disease continues to be the leading cause of death in many countries. According to the World Health Organization, emerging countries will present an enormous growth in the number of heart attacks and, consequently, in the number of deaths.12 Even considering the relative simplicity of diagnosing and treating STEMI, it is uncertain whether or not basic training can substantially reduce mortality rates. In the public hospitals of São Paulo, only those with specialized cardiology units can provide PCI, and STEMI-associated mortality is acceptable (6 to 7%) in these hospitals. Some of the 24 hospitals unable to provide interventional cardiology treatment had a >15% STEMI-associated death rate in 2009, according to data from the Health Secretariat of the State of São Paulo.13 The Society of Cardiology in the State of São Paulo has trained cardiologists, including for the diagnosis and treatment of STEMI, since 1976, but has never trained non-cardiologist emergency personnel. The residents of São Paulo do not usually call 193 (similar to 911 in the United States) for acute chest pain, but instead go to emergency rooms, basic health units, and general hospitals in the city. Therefore, we aimed at reducing in-hospital STEMI-associated mortality rates by providing a training program to emergency personnel  in the city of São Paulo.Training, retraining, and revising are important tools for any medical update, but this may not be necessary for very basic training. Many similar initiatives have brought clear results in other countries.After three meetings with the heads of emergency units and hospital emergency departments, the Society of Cardiology, together with the Secretariat of Health in the State of São Paulo and the Secretariat of Health in the city of São Paulo, designed a training program.We pre-determined a first target: to teach personnel in the five hospitals with more than 100 STEMI patients per year and ≥15% in-hospital STEMI-associated mortality rate. For these five hospitals, we performed on-site training on Saturdays. During the meetings, we observed that many participants feared starting thrombolytic therapy.Besides on-site training, we used internet tools for online training, had update meetings, such as symposia for up to 400 participants 2-4 times each year, created informative online folders and handouts. On-site meetings and the symposia included a four-hour training program with three seminars discussing differential diagnosis of chest pain, thoracic pain, and diagnosis and treatment of acute myocardial infarction (AMI) in the emergency department. After each training, a Q&A session was held. Physicians, nurses and other emergency personnel were invited.The main goal was to evaluate the effects of the training on in-hospital STEMI-associated mortality rates. During this three-year period, streptokinase was replaced with tenecteplase in some hospitals. After treatment with the thrombolytic, aspirin, clopidogrel, and enoxaparin, patients were transferred to a tertiary hospital capable of providing interventional cardiology treatment and surgery. The incidence of AMI and associated death rate was updated every semester by the Secretariat of Health in the State of São Paulo. This information came from public hospitals, which filled out forms including admission, discharge and in-hospital mortality rates.To evaluate the influence of both the training program and the strategy of tecnecteplase followed by transfer to a reference hospital on mortality rates, we specifically monitored one hospital in which tecnecteplase was introduced and evaluated mortality rates after four months of training, and then after the onset of the tenecteplase strategy along the years, after 2013 until 2015. Besides, we took the same data from five other hospitals with ≥15% in-hospital STEMI-associated mortality rate as a control. An Institutional Review Board (IRB) approved this study, whose data was collected from the Secretariat of Health in the State of São Paulo, Brazil.®, version 4.02.9.14 P-value was significant when < 0.05.For this study, we obtained data from the Secretariat of Health in the city of São Paulo. The database contained data from each health unit where a patient had been admitted by generating an authorization for hospitalization. We used number of deaths (N) and mortality rates (%) to perform the two proportion comparison test, using the statistic software Primer of BiostatisticsWe provided on-site training to the emergency personnel in five hospitals and extended the training to three other hospitals in 2010. The same participants were retrained in online meetings and update symposia. Twelve emergency units also trained their staff. Many other hospitals trained their emergency and intensive care unit personnel from 2011 to 2013. In total, nearly 200 physicians and 350 nurses attended at least one training session from May, 2010, to December, 2013. We observed that many emergency physicians were unable to identify an AMI on the electrocardiogram. Nearly 50 emergency departments used tele-electrocardiography, causing a five-minute delay in diagnosis. Even in those departments, the emergency staff often feared starting thrombolytic therapy. The STEMI-associated death rates in the five pre-determined hospitals (numbered from 1 to 5) with on-site training reduced their rates from 25.9%, in 2009, to 18.3%, in 2010, with significant difference (p < 0.001)   . The fiOver the three-year period, the number of diagnosed myocardial infarctions increased by 12.61%. However, the number of deaths decreased by 177, an absolute reduction of 3.06% and a relative risk reduction of 21.39%.Data from the monitored hospital were as follows: this hospital , compared to the data in the United States (5.9%).13 The absolute increase in the number of cases of AMI from 2010 to 2013 is in accordance with the projections from the World Health Organization,1 and is supposed to grow even more in the next twenty years. In this study, basic training of emergency personnel caused a significant reduction in the number of deaths due to AMI , with an absolute reduction of 3.06%. In fact, there were two main issues addressed by the training program: difficulty in interpreting an electrocardiogram; and fear of prescribing thrombolytic therapy due to the possibility of brain bleed. We know that these achieved results must be maintained, and we consider this will only be possible with a continuous training program directed to emergency personnel. We acknowledge the possibility that the strategy of treating AMI with tenecteplase, followed by transfer to a reference hospital, could have contributed with the observed reduction in mortality rates. However, as we had pre-established the monitoring of one hospital, it was possible to observe an impressive mortality reduction: from 23.7% to 13.9%, even before the beginning of the strategy with tenecteplase and just four months after the training had started. The non-trained hospitals did not show any differences in this period, and some of them even presented higher mortality rates instead. Unfortunately, mortality rates continue to rise among STEMI patients in our city, and efforts to change this scenario should strongly consider the strategy of training emergency personnel and giving support through tele- electrocardiography and telemedicine.The percentage of deaths caused by AMI remained stable from 2002 to 2009.The study had some limitations. It was not possible to have all the data we wanted, such as the exact number of trained professionals, the number of retrained professionals, the onset of symptoms, the onset-to-door and door-to-balloon times, as well as door-to-thrombolysis time. The data were from a few years ago, but nowadays public hospitals that are similar to that in this study still do not have a routine to carry out thrombolysis or immediate transfer to hospitals that are capable of PCI.In conclusion, the training of emergency personnel significantly reduced AMI in-hospital morbidity and mortality rates. The strategy of implementing personnel training and retraining in public hospitals is life-saving.