AMB Guidelines: COVID –19

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors.

The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

The Brazilian Medical Association comprises various Specialty Societies, interacts with the Health System, public and private, municipal, state, and federal, and actively participates in the international scientific community through the World Medical Association and many other health institutions involved in education, assistance, or research.

These characteristics provide the AMB (board of director, scientific board, and departments) with unique and updated knowledge, a broad and concrete perspective of the facts as they are and not as we are, which along with our willingness to contribute to the national health system, allows our technical body to draw up recommendations that are autonomous, unbiased, transparent, and based on scientific evidence, mainly and including in emergency, conflict, and serious situations, as is the case with the Coronavirus (COVID-19).

Thinking of these recommendations from a practical point of view to aid in the decision-making by the Brazilian health system, these were divided into 4 main areas: 1. Know where the cases are (early diagnosis and prevalence of COVID-19 patients); 2. Directed hospital or home isolation (early diagnosis) and social isolation (to prevent spread by undiagnosed cases); 3. Protection of healthcare professionals (protect the health of professionals, maintain the workforce, and avoid dissemination by professionals); 4. Develop a health care structure capable of properly handling more severe cases that require hospitalization, particularly in Intensive Care Units (ICU).

The evidence used to support these recommendations is based on the mistakes and successes of the international community in the management of COVID-19 cases and on the assumption of its consequences on the control of the epidemiological spread, the reduction of mortality, and in fighting the course of the disease up until the year 2021.

The seven propositional elements in this assessment expressed in the following sequence support the recommendations. However, it is important to remember that they may suffer changes and incorporations as required by the evidence available and the national context, singe these are undergoing daily dynamic changes:

1. Know where the cases are (early diagnosis and prevalence of COVID-19 patients); 2. Directed hospital or home isolation (early diagnosis) and social isolation (to prevent spread by undiagnosed cases); 3. Protection of healthcare professionals (protect the health of professionals, maintain the workforce, and avoid dissemination by professionals); 4. Pre- and intra-hospital treatment; 5. Shared decision making; 6. Mental health; 7. A health care structure capable of properly handling more severe cases that require hospitalization, particularly in Intensive Care Units (ICU), maintaining proper assistance to non-COVID-19 patients.

Issues related to the return to common activities of everyday life, both of health care or community life, are not the scope of these recommendations given its current degree of uncertainty as measured by the indices of national viral circulation, as well as the different realities in several regions of the country.

RECOMMENDATIONS

The 10 recommendations deal with some of the best practices for diagnosis, treatment, prevention, and protection to the population, patients, doctors, and health professionals, in scenarios of unpredictability, uncertainty and that require rapid decision-making as in primary care, emergency or intensive care, or even in community environments or elective assistance in the care of patients with suspected or confirmed COVID-19, as well as in the general population or with other diseases:

1. The Brazilian health system must adopt and maintain austere, intense and constant measures to minimize the effects that now affect the Brazilian population in the context of the worldwide COVID-19 epidemic (pandemic);

2. Ensure hospital infrastructure with specific and isolated areas to care for suspected and sick patients, with specific hygiene and transport measures, and a guaranteed sufficient number of beds, particularly for critically ill patients in intensive care units associated with a sufficient number of respirators for respiratory care. Ensure the appropriate hospital care, thus minimizing the risk of contagion for non-COVID-19 patients¹ - ⁷ ;

3. Constantly consider the index of system collapse (strain of the beds available, including ICU ones) in strategies for implementing additional beds to fill the gaps⁸ ;

4. Ensure the provision and availability of protective equipment to health professionals, particularly those exposed to suspected or confirmed cases, with the following available for use during procedures: cap, mask (preferably N95), face shield, goggles, disposable and waterproof apron, and respirator⁹ - ²³ ;

5. Actively test patients with suspected COVID-19 by PCR, as well as those close to them who could have been contaminated, isolating (block) and monitoring confirmed patients, whenever possible in a community environment or through hospitalization; community isolation (lockdown) proportional to the mortality and/or number of cases diagnosed in the area, particularly of patients in risk groups²⁴ - ⁴⁰ ;

6. Organize multi-professional committees to discuss the care priorities and community strategies according to scientific and ethical criteria to assist in decision-making in the context of the national epidemic;

7. There is no evidence to support the use of any pre-hospital treatment, both as a prophylactic (to reduce the incidence of new cases) or in suspected or confirmed cases (to reduce mortality) ⁴¹ - ⁵⁰ ;

8. The use of dexamethasone in hospitalized patients who require oxygen supplementation seems to reduce mortality⁵¹ ;

9. Provide emotional support for healthcare professionals and patients, as necessary and as symptoms of psychological/psychiatric nature are identified⁵² - ⁶³ ;

10. The decisions between doctor and patient must follow the principles of shared decision-making, in which the patient is adequately informed of the benefits or absence of benefits, as well as the risks, to actively participate in the medical decision⁶⁴ - ⁷⁵ . In addition, the AMB stands firmly in favor of the autonomy of doctors and patients, under the terms of the Helsinki Declaration, of which we are signatory⁷⁶ .

Acknowledgments

Luca Bernardo, Filipe Bernardo, and Fernanda Bley for aiding in the search and selection of evidence and drafting.

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  WMA declaration of Helsinki – ethical principles for medical research involving human subjects. Disponível em: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/
  » https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/

Publication Dates

• Publication in this collection
  21 Sept 2020
• Date of issue
  2020

History

• Received
  July 2020