Summary
- In a city that never sleeps, how can we ensure fast, safe, and high-quality emergency care for everyone? The UPA em Ação project offers a clear example of how improvement methods can support consistent, reliable emergency care across multiple sites.
Every day in São Paulo — a city of more than 12 million people — thousands seek care at the Emergency Care Unit, or Unidade de Pronto Atendimento (UPA) in Portuguese. Located within communities and outside hospital settings, UPAs are often the first — and sometimes the only — point of access for people in critical situations: a child struggling to breathe, an older adult with stroke symptoms, a pregnant woman in pain.
Behind each encounter is the heart of Brazil’s public health system: universal, robust, and deeply committed to equity. Yet challenges persist. Care for potentially life threatening conditions often varies across teams and units, and consistent use of clinical protocols still needs strengthening. As a result, timely and safe care can depend on circumstances rather than reliability.
This reality gave rise to UPA em Ação, an initiative led by São Paulo’s Municipal Health Secretariat to strengthen quality and patient safety in 11 UPAs across the city. The project began with a simple but powerful question: How can we make emergency care reliable and free from variation?
Developed in partnership with the Executive Secretariat for Primary Care, Specialty Care, and Health Surveillance of the São Paulo Municipal Health Secretariat, Einstein Hospital Israelita, and IHI, UPA em Ação transformed 11 pilot UPAs into living laboratories for improvement. These units are spaces where professionals are supported to deliver the right care, at the right time, for every patient with a life threatening condition — saving lives and strengthening Brazil’s Unified Health System, or Sistema Único de Saúde (SUS).
The 5Rs: from “Failure to Rescue” to a Culture of Continuous Improvement
Inspired by the international concept of “failure to rescue”, the project introduced changes that reduce waste, prevent harm, and build trust.
The foundation of the initiative is the 5Rs model: Recognize, Rescue, Reassess, Refer, and Reflect — in the management of patients with life-threatening conditions (LTC). The model combines clinical expertise with people‑centered improvement science. The focus is not only on what to do, but on how to do it reliably, every time, for every patient. The fifth R, Reflect, closes the loop. Teams review results, celebrate successes, and adjust quickly. This often‑overlooked practice sustains gains and strengthens collective learning.
This approach has proven results. In Scotland, it helped make sepsis care more consistent and safer. In Brazil, it contributed to a 100 percent reduction in maternal deaths from sepsis in focused projects. In African countries, it supported a 36 percent reduction in postoperative mortality. Now, the model has been adapted to São Paulo’s UPAs. The IHI team in Latin America was confident that the 5Rs would significantly elevate the quality and safety of patient care and save many lives.
Turning Evidence into Daily Practice
To make this vision operational, the project introduced CARE PATHS (Patient Assistance Tracking and Health Standards), or TRILHAS in Portuguese (Termo de Registro Integrado de Linha de Assistência) — structured flows that integrate clinical guidance, decision support tools, and documentation standards. Their goal is to reduce variation and cognitive load during critical moments.
“Each TRILHA or PATHS is more than a protocol,” explained Daniela Siccardi, IHI Director and project lead. “It’s a visual map of care — a kanban that shows what has been done and what still needs to happen while the patient is being treated.”
So far, PATHS to manage eight LTCs have been implemented: adult and pediatric sepsis, acute myocardial infarction, stroke, adult and pediatric respiratory failure, trauma, acute abdomen, heart failure, and violence detection.
For Adriana Gonçalves dos Santos, a nurse at UPA Tatuapé, “The PATHS is life. It helps us care for patients more safely and reduces the risk of errors.”
Results That Tell a Human Story
In just nine months, measurable improvements emerged:
- National Early Warning Score 2 (NEWS2) adherence at admission increased from 0 to 99 percent
- Sepsis bundle adherence improved from 26 percent to 89 percent
- Timely rescue in heart attacks improved from 62 percent to 90 percent
And more importantly, the general mortality rate was reduced by 15 percent. More than 72 lives were saved since the beginning of the project.
Behind these numbers are lives saved and health care professionals who feel more confident and proud of their work. As Márcio Silva Chaves, Marcelo Lima Nascimento, and Adriana Benetti from UPA Perus noted, “The project reduced care variability and brought teams together around a shared purpose: delivering a better experience for patients and health care professionals."
More Than Technique: A Cultural Shift
“Today, in participating UPAs, the 5Rs and PATHS are part of daily routine,” says Maísa Ferreira, RN and Technical Expert for the Executive Secretariat for Primary Care, Specialty Care, and Health Surveillance of the São Paulo Municipal Health Department. “Nurses review scores during shift handovers, leaders run brief huddles, and a shared sense of purpose is visible in care. The PATHS became the new way of managing LTC in all UPA.
“UPA em Ação, an emergency care initiative transforming São Paulo’s urgent care centers, proves that equity and excellence can thrive together — even in a city as dynamic and complex as São Paulo — where every rescue is valued and every moment of reflection becomes an opportunity for growth. This initiative inspires both teams and patients, showing that when we prioritize every life and continuously learn from each experience, remarkable progress is not just possible, but inevitable,” concluded Ferreira.
Looking Ahead
As the project evolves, its lessons resonate beyond São Paulo:
- Standardization is not rigidity — it’s reliability with compassion.
- Measurement is not just counting — it’s giving meaning to work.
- Improvement is not an event — it’s a way of working together in service of life.
The next phase will deepen leadership engagement, integrate data systems, and ensure the long term sustainability of the 5Rs across São Paulo’s UPA.
Ederson Almeida, Director of Excellence in Healthcare at Einstein Hospital Israelita, stated, “This project exemplifies the Quintuple Aim by enhancing patient and provider experience, reducing waste and costs, improving population health, and centering equity in care.”
Paulo Borem is a Senior Director in IHI’s Latin American region.
Photos provided by the UPA em Ação project team
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