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EMERGENCY CARE PROTOCOLS: CHALLENGES AND BEST PRACTICES
IN BRAZILIAN NURSING
Valeria Candida de Oliveira1
Abstract: The Critical Role of Nursing in Brazil’s Emergency System Emergency care is a fundamental
pillar of the Brazilian Unied Health System (SUS). Nursing professionals are the central workforce
in the operation and management of these high-stakes services. This feature article provides an in-
depth analysis of the emergency care protocols used in Brazilian nursing, examining the persistent
challenges and the evidence-based best practices that are emerging from clinical practice and scientic
literature. Our analysis, based on ofcial documents from the Ministry of Health, resolutions from the
Federal Nursing Council (COFEN), and relevant scientic articles, reveals a critical tension. While
established protocols like the Manchester Triage System and the National Emergency Care Policy
(PNAU) exist, their effective implementation is severely hampered by structural, organizational, and
professional challenges. Key Obstacles Identied: Chronic overcrowding, Insufcient resources, High
occupational stress, Low adherence to safety protocols. Conversely, best practices in areas such as
mechanical ventilation, infection prevention, and patient safety offer clear pathways for improving
care quality. The conclusion is clear: strengthening emergency nursing in Brazil requires overcoming
systemic issues, investing in continuous professional training, and ensuring the consistent application
1 Represents a gure of renowned knowledge in the Brazilian and international nursing lands-
cape. Her career of more than two decades is the embodiment of a powerful and rarely found synergy:
elite performance in high-pressure clinical environments — such as Intensive Care Units, pre-hospital
care, and the frontline of the COVID-19 pandemic — combined with a robust intellectual output that
positions her as an authoritative voice in patient safety, emergency protocols, and geriatric care. e
recognition of her work transcends the hospital environment, being validated by publications in nur-
sing journals, prominence in specialized media, and, emphatically, by the testimony of doctors and
nurses who describe her not only as a competent professional but as a pillar of safety and a technical
and human reference for her teams. is biography details the trajectory of a nurse whose clinical
practice saves lives, whose research informs the eld, and whose educational legacy shapes the future
of the profession.
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of protocols for safer, more effective, and humanized care.
Keywords: Emergency Nursing; Clinical Protocols; Emergency Medical Services; Public Health;
Quality of Health Care.
INTRODUCTION: The High-Stakes Environment
Emergency services serve as the primary entry point to the SUS for a signicant portion
of the Brazilian population. This environment is characterized by its dynamic, high-complexity,
and unpredictable nature, demanding agile, technical, and coordinated professional action to ensure
patient stability and prevent adverse outcomes. The nursing team is crucial, managing everything
from patient reception and risk classication to complex procedures and overall care management.
To standardize workows and ensure the quality and safety of care, a variety of protocols
have been implemented. The PNAU, established in 2003, organizes the care network, integrating
key components such as the Mobile Emergency Care Service (SAMU 192), Emergency Care Units
(UPAs), and hospital entry points (BRASIL, 2006). The Manchester Triage System is the dominant
clinical tool for screening and prioritizing patients, guiding resource allocation based on clinical
severity (MORSCH, 2024).
However, the reality of implementation is fraught with difculty. Chronic overcrowding,
a lack of material and human resources, network fragmentation, and stressful working conditions
directly compromise the ability of nursing professionals to adhere to guidelines and deliver high-
quality care. Studies consistently highlight overcrowding management as a major managerial challenge
(SANTOS et al., 2013), alongside difculties in fully implementing the Nursing Care Systematization
(SAE) (MARIA; QUADROS; GRASSI, 2012).
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METHODOLOGY (Literature Review)
This feature is based on a narrative and analytical literature review, drawing from scientic
productions in the SciELO and PubMed databases, as well as ofcial guidelines from the Brazilian
Ministry of Health and COFEN. The analysis was structured around three main axes: Protocols and
Guidelines, which are the normative frameworks regulating emergency nursing practice; Challenges,
focusing on the structural, care-related, and professional obstacles to implementation; and Best
Practices, which are the evidence-based strategies for improving care quality.
RESULTS AND DISCUSSION
Foundational Protocols: The Framework of Care
The practice of emergency nursing in Brazil is structured by key regulatory instruments.
The Manchester Triage System (MTS) serves as the primary screening and prioritization tool, using
a ve-color system to allocate resources based on severity. The National Emergency Care Policy
(PNAU) organizes the national emergency care network, integrating components like SAMU 192,
UPAs, and hospital emergency departments (BRASIL, 2006). Furthermore, COFEN Resolutions
regulate specic professional activities, such as Resolution 713/2022, which standardizes Mobile
Pre-Hospital Care (APH) (CONSELHO FEDERAL DE ENFERMAGEM, 2022), and Resolution
557, which denes airway aspiration as an exclusive nursing activity (CONSELHO FEDERAL DE
ENFERMAGEM, 2017). Finally, the Nursing Care Systematization (SAE) organizes professional
work and operationalizes the nursing process, covering data collection, diagnosis, planning,
implementation, and evaluation.
The Manchester Triage System assigns priority levels and target times for medical care
based on color: Red indicates an Emergency requiring immediate care; Orange is Very Urgent, with
a target time of within 10 minutes; Yellow is Urgent, with a target time of within 60 minutes; Green
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is Less Urgent, with a target time of within 120 minutes; and Blue is Non-Urgent, with a target time
of within 240 minutes. The SAE, while a cornerstone of nursing practice, faces signicant challenges
in emergency settings due to the high-paced dynamics and workload, often leading to fragmented,
task-focused care (MARIA; QUADROS; GRASSI, 2012).
Multifactorial Challenges: The Implementation Gap
The gap between protocol and practice is driven by three categories of challenges:
• Structural and Organizational Challenges: Overcrowding is the most visible and
impactful issue, often cited as the main managerial challenge (SANTOS et al., 2013).
This is compounded by Resource Insufciency, including a lack of step-down beds,
inadequate materials, equipment, and insufcient stafng levels. The direct consequence
is a chaotic work environment that compromises patient safety and elevates team stress.
• Care-Related Challenges: Maintaining care quality in a scenario of overcrowding and
resource scarcity is a Herculean task. Low Adherence to Safety Protocols is a direct
consequence of this context; for example, compliance with oral hygiene using chlorhexidine
for patients on mechanical ventilation was found to be below 50% (SANTOS et al., 2020).
This also includes the difculty in fully implementing the SAE, resulting in Fragmented
Care that is task-focused rather than a holistic patient assessment (MARIA; QUADROS;
GRASSI, 2012).
• Professional Challenges: The emergency environment imposes a high level of Occupational
Stress. The need to make rapid decisions under pressure, constant exposure to suffering
and death, and workload overload contribute to physical and mental exhaustion among
professionals (PESSOA JÚNIOR et al., 2017). Additionally, nurses are required to exercise
Complex Leadership, negotiating conicts, managing scarce resources, and coordinating
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multiprofessional teams—competencies that require specialized development (SANTOS
et al., 2013).
Evidence-Based Best Practices: Pathways to Quality
Despite the obstacles, a robust body of best practices exists to enhance emergency nursing
care. In the area of Patient Safety, this includes Infection Prevention Bundles (e.g., for VAP), which
involve practices like maintaining the head of the bed elevated, checking endotracheal tube cuff
pressure, and oral hygiene with chlorhexidine (SANTOS et al., 2020), all of which lead to a signicant
reduction in adverse events. Infection Control relies on Hand Hygiene and the correct use of Personal
Protective Equipment (PPE), especially during high-risk procedures like airway aspiration (SANTOS
et al., 2020), which remains the most effective and low-cost measure for infection prevention. For
Management, the implementation of the Manchester Triage System and Humanized Reception
(involving qualied listening and comprehensive assessment) is a well-established best practice that
organizes patient ow, prioritizes severe cases, and improves user satisfaction. Finally, Professional
Development through Continuous Education in protocols, leadership skill development, and clinical
case discussions is an essential strategy to bridge the gap between scientic knowledge and daily
practice.
CONCLUSION: A Call for Systemic Investment
The Brazilian emergency nursing landscape is dened by a tension between well-founded
protocols and profound structural decits. Overcrowding, resource shortages, and workload overload
are not merely operational issues; they are systemic barriers that undermine patient safety and care
quality.
The nurse’s role is complex, extending beyond technical execution to the management of
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care in an adverse environment. To support this critical function, health managers must invest in
strengthening the Emergency Care Network, ensuring adequate funding, expanding step-down beds,
and correctly sizing teams. Without addressing these systemic problems, protocols remain detached
documents.
For the nursing profession, the path to qualication involves:
• Consistent incorporation of evidence-based practices (e.g., infection prevention bundles).
• Continuous training and leadership strengthening.
• Adaptation of the SAE to the emergency reality.
Professional valorization and the creation of safer, healthier work environments are
indispensable to mitigate stress and promote humanized care. Excellence in emergency care is a joint
effort: the system must provide structural conditions, institutions must promote effective management
and education, and professionals must pursue constant updating and rigorous application of scientic
knowledge.
REFERENCES
BRASIL. Ministério da Saúde. Política Nacional de Atenção às Urgências. Brasília: Ministério da
Saúde, 2006.
CONSELHO FEDERAL DE ENFERMAGEM (COFEN). Resolução COFEN nº 713/2022. Atualiza
as normas para atuação dos prossionais de enfermagem no Atendimento Pré-Hospitalar (APH)
terrestre e aquaviário. Brasília: COFEN, 2022.
CONSELHO FEDERAL DE ENFERMAGEM (COFEN). Resolução COFEN nº 557/2017. Regulamenta
a atuação da equipe de enfermagem no procedimento de aspiração de vias aéreas. Brasília: COFEN,
2017.
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MARIA, M. A.; QUADROS, F. A. A.; GRASSI, M. F. O. Sistematização da assistência de enfermagem
em serviços de emergência: viabilidade de implementação. Revista Brasileira de Enfermagem, v. 65,
n. 2, p. 297-303, 2012.
MORSCH, Telemedicina. Protocolo de Manchester: o que é, cores e classicação. [Internet], 2024.
PESSOA JÚNIOR, J. M. et al. Estresse nos serviços de urgência e emergência e os desaos para os
enfermeiros brasileiros e portugueses. Revista de Enfermagem Referência, IV Série, n. 12, p. 115-24,
2017.
SANTOS, C.; NASCIMENTO, E. R. P.; HERMIDA, P. M. V. et al. Boas práticas de enfermagem para
pacientes em ventilação mecânica invasiva em emergência hospitalar. Escola Anna Nery, v. 24, n. 2,
2020.
SANTOS, J. L. G.; LIMA, M. A. D. S.; PESTANA, A. L.; GARLET, E. R.; ERDMANN, A. L. Desaos
para a gerência do cuidado em enfermagem em uma emergência na perspectiva dos enfermeiros. Acta
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