Hospital Epidemiology Units in Brazil: an integrative literature review

Núcleos Hospitalares de Epidemiologia no Brasil: uma revisão integrativa de literatura

Unidades de Epidemiología Hospitalaria en Brasil: una revisión integradora de la literatura

Esta obra está bajo una Licencia Creative Commons Atribución 4.0 Internacional.

Epidemiological surveillance has a history dating back to the 19^th century, and was limited to data collection, compilation, assessment and dissemination to health authorities and the general public, with the main objective of early detection of patients with a view to their isolation.¹

The expansion of epidemiological surveillance actions to the hospital level began with Ordinance 2,529 of November 2004, which created the Brazilian National Subsystem of Epidemiological Surveillance in hospital settings and, thus, paved the way for implementing Hospital Epidemiology Units (HEU) as a way of optimizing health surveillance actions from the hospital context, with elements already inherent to epidemiological surveillance, including data collection and processing activities, data analysis and interpretation, recommendation of prevention and control measures, promotion of prevention and control actions, assessment of the effectiveness of the measures adopted and dissemination of relevant information.^2,3,4

In 2010, through Ordinance MoH/MO 2,254 of August 5, 2010, Hospital Epidemiological Surveillance (HES) was established within the Brazilian National Health Surveillance System (SNVS - Sistema Nacional de Vigilância em Saúde). Its purpose was to define an initial network of national reference hospitals for developing epidemiological surveillance actions in hospital settings.³

HEU are structures created to carry out epidemiological surveillance in hospitals and health units. The main objective of these units is to ensure the development of epidemiological surveillance activities in hospital health settings, preventing and controlling diseases, health problems and events (DHE) and other hospital infections. They are made up of healthcare professionals with experience and/or training in public health who work in an articulated manner, aiming to detect, report and investigate illnesses, in close coordination with the Brazilian National Public Health Emergency Alert and Response Network (CIEVS Network) as well as the detection of deaths of women of childbearing age, declared maternal deaths, infant and fetal deaths, deaths from infectious diseases and from ill-defined causes. Thus, they carry out activities such as data collection and analysis, DHE and infection outbreak identification, prevention measure implementation and suspected case investigation.⁵

The activities developed by HEU, within hospital settings, assume structures and work processes guided by guiding ordinances to be developed. Every unit should act by reporting and investigating diseases and injuries through active search, data consolidation, analysis and dissemination of information, promotion of control actions, in addition to assessment of the efficacy and effectiveness of the measures adopted, promotion of integration between key sectors of the hospital and timely monitoring.^6-7

It is important to understand HEU, demonstrating their performance within hospital units and how their production can reflect on local managers’ decision-making and on the knowledge of emerging diseases faster and accurately.

This work aims to map the studies carried out on the structure and/or processes of HEU in Brazil. Carrying out an integrative review on the topic can help identify situations within the units with their connections and divergences.

This is an integrative literature review to map studies on HEU. The types of studies included in the study were full articles published in indexed journals, dissertations and theses. The search period considered was from 1971 to 2022, filtered in the PubMed, Virtual Health Library (VHL), Brazilian Digital Library of Theses and Dissertations (BDTD) and CAPES Journals (CAFe access) databases, using defined strategies, according to Chart 1. The filters used in the databases to search for descriptors were the title or, in the abstract, the descriptors indexed in the aforementioned databases. The studies were exported on December 21, 2022.

The construction of this study was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA 2020) checking and preparation items, aiming to increase the quality and reliability of the information obtained.

Studies that assessed the structure and/or processes and/or outcomes of HEU in Brazil were included. Therefore, articles that studied communicable and non-communicable diseases and injuries, hospital infections and other situations that do not constitute HEU structuring were excluded.

The categorization of studies available in the databases used in the study was carried out by a researcher with experience in HES, using the online platform Rayyan.

The following DeCS terms were used with the combined search strategies and the Boolean operators OR and AND (Chart 1):

The descriptors used in the BDTD platform were inserted in Brazilian Portuguese, as this was more successful in locating available studies.

The process of selecting and organizing the inclusion and exclusion of articles was carried out using Rayyan application, where titles and abstracts were read, duplicates were excluded, the reasons for exclusion were categorized, and the articles were selected for full reading.

An Excel spreadsheet was created to extract data from articles selected for full reading with the following variables: study title; authors; journal name and year of publication; study period; study location; study focus (structure, process or outcome); objective; and study considerations.

All studies (n=1,358; 100%) found through database analysis were exported to Rayyan to exclude duplicates (n=94; 6.92%). After reading the title and abstract, another 1,099 (80.93%) were excluded because they did not match the study objective. Others (n=06, 0.44%) were excluded because they were not available for reading in full. And 159 (11.71%) articles remained for full reading, as shown in Table 1.

After reading the selected articles in full (n=159), we excluded 152 because they were not consistent with the proposed objective. In order to meet the study objective, seven studies were included (Table 1).

We listed the reasons for exclusion of articles after reading titles and abstracts, as observed in the PRISMA flow diagram (Chart 2). We verified studies that had as their research object diseases, injuries and events in public health, and chronic non-communicable illnesses accounted for n=462 (42.2%) of reasons for exclusion.

Table 1
Refinement of analysis performed after exporting articles to the databases

Source: prepared by the author (2023).

In order to identify studies through other methods and further refine the search, the bibliographic references of the seven studies included in database analysis were checked. Thus, we identified 923 bibliographic reference records. After analyzing these references, 11 studies that met the study objectives were eligible, as observed in the PRISMA flow diagram presented in Chart 2.

The PRISMA flow diagram shows that the number of journals reviewed in this process totaled 2,281 records. Eighteen studies were included, identified in the sum of the following search strategies: databases (n=07) and other methods (bibliographic references of articles) (n=11). As this is an integrative review, this research was not submitted to a Research Ethics Committee (REC).

Figure 1
PRISMA 2020 flow diagram: Hospital Epidemiology Units: an integrative literature review

In accordance with the study objectives, 18 studies were included in this integrative review (Figure 2; Chart 3), which can therefore be distributed within the Federative Units (Figure 2).

Figure 2
Distribution of the 18 studies included in the review at national level
Source: prepared by the author.

Source: developed by the author. Caption: N: no; S: structure, P: process, O: outcome.

In the analysis of included studies, we found works by several authors meeting different objectives. We observed that four studies carried out in the states of Pernambuco and Piauí, assessing HEU implementation, recorded moments of progress and setbacks. Moreover, there were deficiencies in the physical and material structure, a shortage of human resources and the need for training, compromising their operationalization.^8,9,12

In turn, a study carried out in the state of Rio de Janeiro in 2017 reports the experience and challenges of implementing HEU. The authors describe that the unit plays a fundamental role as a reporting unit for the municipality and the state.¹⁰

A study conducted in Brasília in 2013 presented a situational diagnosis of the emergency hospital network’s response capacity to events associated with international travelers. The authors observed that notification flows in HEU are not consolidated among professionals and there is a dichotomy between professionals working in care and surveillance.^13,27

Another problem detected was the accumulation of HEU activities, performing, among other functions, the active search for events in hospitals, the investigation of events in their area of coverage, the performance of activities in other sectors concurrently with HEU activities, not having agile and efficient means of communication, revealing a lack of specific training for professionals in surveillance teams and a deficiency of human resources.¹³

A study on HEU in the state of São Paulo indicated that hospital surveillance has been carried out by highly qualified professionals, given their training and experience in the area, with a predominance of nurses. Most services are coordinated by medical professionals. Active search was the predominant form of screening for cases of diseases and conditions requiring compulsory notification, and several strategies were used for this purpose. Study participants considered insufficient human resources, difficulty in raising awareness among healthcare professionals and high workload as factors that hinder work processes.¹⁴

Still in São Paulo, a study carried out between 2006 and 2011, assessing the HEU network, contextualizing structure, work process and outcomes, demonstrated that, from the perspective of physical infrastructure, materials and equipment, the units present favorable conditions both in relation to the adaptation of their structures and in relation to the availability of IT equipment. Most of them face significant staff shortages. There are still some units that are in the process of adapting to certain indicators and need to improve their procedures comprehensively. This involves not only organizing the activities carried out in HEU, but also expanding staff.¹⁵

In order to identify the relationship between the organizational climate in the HEU in the city of Natal, RN, in 2010, it was suggested that the performance of epidemiological surveillance in hospital settings demands professionals with a profile that ranges from the ability to overcome challenges to the ability to raise awareness of care professionals in the process. Furthermore, it is essential to have the necessary flexibility to deal with the transformations imposed by the environment in which the institution is located.¹⁶

Another study conducted in Natal on nurses’ knowledge of HES actions concluded that most nurses are aware of epidemiological surveillance actions, especially notification actions, but do not notify the HEU. Most nurses, when identifying ND, do not communicate them to HEU. As a result, the information is fragmented and lost so that it does not express the performance of integrated work with this core group.¹⁷

Research conducted in Minas Gerais analyzed ND and injuries that occurred in a university hospital’s HEU. Through detailed data analysis, it seeks to inform both the profile of the diseases reported and possible areas for improvement in the notification process and in the response to these events, thus promoting advances in public health management, contributing to implementing new HEU, reorganizing existing ones and preventing communicable diseases.²⁰

A nationwide integrative review of HEU, carried out in 2019, highlighted that the obstacles to the full operationalization of HEU included: lack of staff training; lack of institutional support; low prioritization by public management; failure to comply with the requirements and competencies established in the regulation (Ordinance 2,529/2004); lack of periodic training; lack of preparation and publication of information generated by the units; insufficient research; lack of consistent monitoring of vital events in all units; lack of collaboration between unit technicians and Hospital Infection Control Committees (HICC); and underreporting of cases in some HEU.²¹

A study conducted in Brazil in 2015 sought to present the actions of HEU with other levels of healthcare, playing an important role in communication between the points of the Healthcare Network. The information obtained in hospital settings is of great importance and aids decision-making, contributing to meeting the health system’s needs.²²

A study carried out in a municipality of Cascavel in the state of Paraná revealed that underreporting notifiable diseases in hospital settings is a significant concern for health authorities and that there is a tendency to underestimate the real incidence of diseases due to several factors, such as lack of awareness, inadequate knowledge of notification protocols, reputational concerns and possible legal consequences.²³

Seeking to verify an integrated practice between HES and Hospital Infection Control Service, a study carried out in the RJ-SP axis highlighted that collaboration between different types of surveillance, such as epidemiological and infection control, can result in a more comprehensive understanding of health risks. However, the research also identifies obstacles, such as the lack of effective communication between different teams and the lack of sharing of relevant data.²⁴

In relation to searches for studies on HEU, we came across studies that present as the object of study, for instance, the diseases and injuries reported by the unit, such as healthcare-associated infections. However, these studies report, in parallel, on the organization functioning or system. From this, we can verify parts of the HES operationalization systematics, whether focusing on the structure, process or outcome. This occurs mainly in international studies.^25-28

The study presented 18 publications of studies on structure and/or processes and/or outcomes on HEU, distributed nationwide.

It was identified that the studies address topics such as notification and investigation of diseases and injuries and active search. Some even verticalize analyses on integration between sectors within hospital settings and the external care network. However, there are few studies that analyze the performance of the units – analysis of process and outcomes, considering dissemination of information, promotion of control actions and assessment of the efficacy and effectiveness of the measures adopted. We emphasize that the performance of a HEU must contemplate all these activities.

For now, this study provides an overview of HEU in the scientific literature, allowing a broader view of HEU scenarios, although studies on this subject are scarce. We therefore highlight the importance of studies that investigate the functioning and work process of these operational units (HEU) within hospitals, as well as their contribution to public health.