Impact of structured multiprofessional rounds on clinical outcomes in a resource-limited intensive care unit: A retrospective study

Abstract

Effective communication among intensive care professionals is essential for patient safety and outcome optimization. Multiprofessional rounds supported by checklists have demonstrated the potential to improve the quality of care, particularly in high-income settings. However, evidence remains limited for low- and middle-income countries (LMICs). We conducted a retrospective observational cohort study of 652 adult patients admitted to the ICU of a tertiary public hospital in Brazil between January 2021 and December 2022. Clinical outcomes were compared for 1 year before and 1 year after the implementation of structured daily multiprofessional rounds, which were guided by a standardized checklist. Clinical severity (SAPS 3), standardized mortality ratio (SMR), invasive mechanical ventilation (IMV), and device use were analyzed using univariate tests and Pearson correlations. Despite a significant increase in illness severity postintervention (SAPS 3: 39.4 vs 60.6; P = .005), the postintervention group showed a substantial reduction in SMR (3.7 to 0.8; P = .001) and IMV duration (10 to 7 days; P = .003). Device usage increased proportionally with the patient acuity. A moderate positive correlation was observed between the SAPS 3 and central venous catheter (CVC) use (R = 0.662; P = .019). The implementation of structured multiprofessional rounds with checklists in a resource-limited public ICU was associated with improved clinical outcomes. Although these findings are promising, future studies with multivariate and prospective designs are required to establish causal relationships.

1. Introduction

Patients admitted to Intensive Care Units (ICUs) require complex and continuous care, necessitating the integrated involvement of multiprofessional teams.^[1,2] The quality of communication among health care professionals is a critical determinant of patient safety and clinical outcomes, with communication failure being the leading cause of adverse events and inappropriate therapeutic decisions.

Daily multiprofessional rounds have emerged as a care management strategy aimed at optimizing communication, aligning treatment plans, and reducing omissions and rework.^[3,4] The incorporation of structured checklists during these rounds has proven effective in standardizing care, increasing adherence to evidence-based practices, and reducing negative outcomes, such as the duration of invasive mechanical ventilation (IMV) and hospital mortality.

Although international literature, particularly from high-income countries, has already demonstrated the benefits of this practice, the reality of public hospitals in low- and middle-income countries, such as Brazil, is markedly different. The scarcity of material and human resources, combined with fragile clinical management processes, hinders the implementation and evaluation of organizational interventions such as structured rounds. Moreover, there is a lack of national studies that robustly assess the impact of these strategies on public ICUs.^[5–9]

Until the end of 2021, the ICU analyzed in this study exhibited a high standardized mortality rate (3.6), lacked a quality management system, and did not perform regular multiprofessional rounds. In January 2022, a management plan was implemented focusing on the daily execution of multiple rounds, guided by a structured checklist and supported by quality improvement tools, such as the PDCA cycle and Lean Healthcare principles.

In this context, the present study aimed to evaluate the impact of implementing structured multiprofessional rounds using a checklist on the clinical outcomes of critically ill patients in a Brazilian public ICU with limited resources. The main objective was to evaluate the impact of the intervention on reducing the standardized mortality rate, as well as its effects on the duration of mechanical ventilation and use of other devices. We hypothesized that the intervention would have a positive impact on reducing the indicators.

This study seeks to address a gap in the national literature and contribute evidence applicable to similar resource-constrained settings, thereby strengthening cost-effective and replicable care practices within the Unified Health System (SUS).^[2,5,10]

2. Methods

2.1. Study design and population

This retrospective cohort observational study was designed to evaluate the impact of implementing structured multiprofessional rounds, guided by a standardized checklist, on the clinical outcomes of patients admitted to the Intensive Care Unit (ICU) of the Hospital Municipal Djalma Marques (HMDM) in São Luís, Brazil.

A retrospective design was chosen to leverage the data already recorded in the EPIMED Monitor® system to reduce the collection bias and resource demands associated with prospective studies. All adult patients admitted to the ICU between January 1, 2021, and December 31, 2022, were included, covering 1 year before and 1 year after the intervention, which started in January 2022. The sample was defined by a temporal criterion of convenience, with no sample size calculation. As this study was designed in accordance with the recommendations of The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

2.2. Ethics and funding

The study was approved by the local Research Ethics Committee and validated by the National Research Ethics Council (CONEP) under protocol number 6.482.710 (CAAE: 74369723.60000.5085). Because this study involved only retrospective data without patient identifiers, the requirement for informed consent was waived. This research was supported and sponsored by the Foundation for Research and Scientific and Technological Development Support of Maranhão (FAPEMA), a public research support entity of the Government of Maranhão.

2.3. Inclusion and exclusion criteria

The study population consisted of 739 adult patients (aged ≥ 18 years) admitted to a general ICU with 10 beds, specializing in trauma and emergency care. The included patients had a minimum ICU stay of 48 hours and no confirmed COVID-19 infection. Patients were excluded if they had suspected brain death on admission (7 patients), were under exclusive palliative care (1 patient), had confirmed or suspected COVID-19 infection (8 patients), had an ICU stay of <48 hours (71) or did not meet any of the eligibility criteria. After applying the exclusion criteria, 652 patients were included in the analysis, 320 in the preintervention group and 332 in the postintervention group.

The exclusion of COVID-19 cases was intended to minimize confounding factors related to the high clinical variability and uncertainty in therapeutic protocols during the pandemic period.

2.4. Intervention: checklist design and implementation

The intervention consisted of implementing structured daily multiprofessional rounds guided by a validated checklist, starting on January 1, 2022. The checklist was developed through an internal consensus among ICU professionals and included 33 care items spanning the medical, nursing, physical therapy, nutrition, pharmacy, speech therapy, dental, psychological, and social service domains (Fig. 1).

Figure 1.

Checklist used in the daily multiprofessional rounds with participation from physicians, nurses, physiotherapists, nutritionists, dentists, psychologists, pharmacists, speech therapists, and social workers.

The multiprofessional rounds were conducted every weekday in the morning, lasting approximately 1 hour. The mandatory participants included physicians, nurses, and physical therapists, who regularly participated as nutritionists, pharmacists, and social workers. Dentists, speech therapists, and psychologists were involved on an as-needed basis, according to patient care demands. Each professional was responsible for evaluating and completing the relevant checklist items using standardized response options.

Prior to the official implementation of the structured rounds, the ICU team underwent a brief orientation session to introduce the checklist and standardize its use. However, no formal transition phase, extended training, or pilot testing has been conducted. The intervention was launched as a quality improvement initiative in January 2022 with the aim of integrating all relevant professionals into daily practice. In our opinion, the lack of extensive training did not negatively impact the protocol, since the leaders and participants involved were with the team daily, ensuring the quality of execution.

Adherence to the multiprofessional round protocol, including the frequency of completed rounds and consistency in checklist use, was not formally monitored or recorded during the study period. Therefore, quantitative data on protocol fidelity and participation rates for each professional category were unavailable. This represents an important limitation of the present study, and should be considered when interpreting the results, particularly regarding the internal validity and reproducibility of the intervention.

2.5. Data collection and variables

Data were extracted from the EPIMED Monitor® system and compiled into an identifiable database. The collected variables included sociodemographic characteristics (age and sex), clinical severity (SAPS 3 score), use and duration of IMV, central venous catheter (CVC) use, indwelling urinary catheter (IUC) use, length of ICU stay, and standardized mortality ratio (SMR).

2.6. Statistical analysis

Descriptive statistics were used to summarize the data. Continuous variables were tested for normality using the Shapiro–Wilk test. Normally distributed variables were compared using the Student t test for independent samples, and non-normal variables were compared using the Mann–Whitney U test. A significance level of P < .05 was adopted for all analyses. Pearson correlation coefficient was used to assess the linear relationship between the severity score (SAPS 3) and use of invasive devices. Effect sizes and confidence intervals were not reported due to the descriptive and exploratory nature of the analysis but should be included in future studies.

Although univariate analyses were conducted, multivariate modeling (such as logistic regression) was not performed owing to limitations in the available dataset, including missing data on important potential confounders (e.g., comorbidities and functional status). As a result, it was not possible to adequately adjust for baseline imbalances, such as the higher severity of illness observed in the postintervention group. This methodological constraint restricts causal inferences regarding the effects of the intervention. Future studies with more comprehensive data collection are required to address these limitations.

The analysis of correlations between the SAPS 3 scores and invasive device use was performed as an exploratory approach, a hypothesis-generating analysis to better understand the relationship between patient severity and clinical practices within the ICU. This was not a pre-specified primary outcome but was included to generate hypotheses for future studies. This was not part of our predefined primary or secondary outcomes but was included to better understand practice patterns and their relationship with patient acuity. The results should be interpreted with caution and warrant further investigation in future studies.

All statistical analyses were performed using IBM SPSS Statistics (version 20.0; IBM Corp., Armonk, NY) and Google Sheets.

3. Results

3.1. Baseline characteristics

The analysis included 652 non-COVID-19 patients: 320 in the preintervention group and 332 in the postintervention group. Data were analyzed at aggregated monthly intervals (n = 12 for each period). ICU occupancy remained high in both periods (96.5% preintervention vs 100% postintervention, P = .551), and the mean patient age was similar between the groups (46.7 vs 47.9 years, P = .590) (Table 1). However, patient severity, as measured by SAPS 3, was significantly higher in the postintervention group (39.4 ± 4.88 vs 60.63 ± 7.45, P < .001) (Table 1). The absolute number of emergency clinic admissions was 120 (50%) in the preintervention group and 121 (49.7%) in the postintervention group.

Table 1.

Comparison of clinical variables between the groups 1 year before and 1 year after the implementation of daily multiprofessional rounds.

Category	Pre-rounds (n = 12)	Post-rounds (n = 12)	P-value
Monthly admissions	26.67 ± 7.75	27.67 ± 5.05	.712*
Patients-days	233 [211–248]	240 [233–244]	.514†
ICU occupancy rate (%)	96.50 [88.2–102]	100 [95.5–102]	.551†
Mean age	46.7 [44.2–48.7]	47.9 [42.7–56.1]	.590†
ICU length of stay (d)	13.24 ± 4.83	12.71 ± 4.17	.779*
Monthly medical admissions	10 ± 4.57	10.1 ± 4.4	.928*
Monthly surgical admissions	10 ± 2.69	10 ± 3.60	.949*
Mean SAPS 3	39.40 ± 4.88	60.63 ± 7.45	<.001*
Predicted mortality rate (%)	10.5 [5.5–15.7]	41.5 [27–47]	<.001†
Mortality rate (%)	37.0 [30.5–53.2]	35.5 [21.2–42.0]	.266†
Standardized mortality ratio	3.6 [2.4–6.0]	0.7 [0.5–1.4]	<.001†
Patient-days using CVC	101.5 ± 55.63	161.33 ± 31.90	.004*
CVC utilization rate (%)	42.92 ± 21.48	67.50 ± 12.51	.002*
Patient-days using IUC	171 [109–211]	210 [181–220]	.033†
IUC utilization rate (%)	71.5 [52.7–88.2]	88.0 [77.5–91.5]	.060†
Patient-days using IMV	140 [85–163]	155 [132–166]	.219†
IMV utilization rate (%)	55.08 ± 13.98	63.42 ± 10.63	.115*
IMV duration (d)	9.5 [8–10]	7 [6–8]	.017†

CVC = central venous catheter, IMV = invasive mechanical ventilation, IUC = indwelling urinary catheter, SAPS 3 = Simplified Acute Physiology Score 3.

^*Student t-test for independent samples.

^†Mann–Whitney U test.

3.2. Disease severity and clinical outcomes

Despite the increased illness severity in the postintervention group, the SMR decreased significantly from 3.7 to 0.8 (P = .001), and the average duration of IMV declined from 10 to 7 days (P = .003). The mean number of patients with CVCs increased from 102 to 161 (P = .002), and the mean number of patient-days with IUCs increased from 166 to 210 (P = .002). Although the percentage of patients requiring IMV increased from 55% to 63%, the difference was not statistically significant (P = .057).

Notably, these results suggest a favorable impact of the intervention, even under more complex clinical conditions (Table 1). Additional analysis showed an increase in the number of patient-days using invasive devices, likely reflecting the higher acuity of the postintervention population.

While our results suggest that structured multiprofessional rounds may improve clinical outcomes, the retrospective observational design and absence of multivariate risk adjustment preclude firm causal inferences. We urge caution in interpreting these associations and recommend that future research employ more rigorous analytic approaches, since the observed improvements cannot be interpreted as causal because of the absence of multivariate adjustment.

3.3. Correlation analysis

A moderate positive correlation was observed between patient severity (mean SAPS 3) and both the duration and rate of CVC use (R = 0.662 and R = 0.672, respectively; P < .05), indicating that more severely ill patients required longer and more frequent use of invasive central lines. No significant correlations were found between the SAPS 3 and urinary catheter use (Table 2).

Table 2.

Comparison of correlations between clinical variables.

Category	Correlation coefficient (r)	P-value	Correlation strength
Mean SAPS 3 and patient-days using CVC	0.726	<.001*	Strong and positive
Mean SAPS 3 and CVC utilization rate	0.731	<.001*	Strong and positive
Mean SAPS 3 and patient-days using IUC	0.667	<.001†	Moderate and positive
Mean SAPS 3 and IUC utilization rate	0.599	.002†	Moderate and positive

CVC = central venous catheter, IUC = indwelling urinary catheter, SAPS 3 = Simplified Acute Physiology Score 3.

^*Pearson correlation test.

^†Spearman correlation test.

4. Discussion

4.1. Primary outcomes

This study demonstrated that the implementation of structured daily multiprofessional rounds, supported by a standardized checklist, was associated with a significant reduction in the SMR and duration of mechanical ventilation in a resource-limited public ICU. Notably, these improvements were observed despite a marked increase in patient acuity during the postintervention period.

These findings suggest that targeted organizational interventions, even in low-resource settings, can yield meaningful improvements in clinical outcomes. The positive impact on mortality and mechanical ventilation duration aligns with the hypothesis that structured, team-based care processes enhance the quality and safety of critical care delivery.

Effective ICU management, particularly in underfunded public settings, demands strategies rooted in proven innovative methodologies such as Lean Healthcare and continuous improvement tools such as the PDCA (Plan-Do-Check-Act) cycle.^[11,12] Originating in the automotive industry, leaning has demonstrated its applicability and effectiveness in healthcare by eliminating waste, reducing variability, and maximizing the value delivered to patients.^[12–15]

In public ICUs, where material and human resource shortages are chronic, learning facilitates more organized workflows, reduces idle time and rework, and enhances response times in critical scenarios.^[2,16–20] Lean tools also contribute to patient safety by minimizing errors through standardization and visual management systems.^[4,10,21,22]

The PDCA cycle plays a complementary and essential role in managing ICU quality, particularly in public environments, where continuous improvement and efficiency are necessary.^[23] The PDCA allows structured process implementation involving careful planning, controlled execution, outcome monitoring, and corrective action. In public ICUs, it directly contributes to improved bed management, optimized use of supplies, and reduction of adverse events. Studies have shown that the continued use of PDCA in healthcare institutions results in better clinical and managerial indicators, even under financial constraints.^[24,25] Thus, when combined with Lean, PDCA is a powerful instrument for transforming realities, improving outcomes, and increasing resource efficiency, influenced by the safety model of the aviation industry, which has developed robust safety tools such as structured checklists and intervention bundles that have been successfully transferred to healthcare^.[23,26,27]

Checklists help to standardize complex procedures and avoid critical omissions, thus enhancing the safety and consistency of intensive care. A well-known example is the central line-associated bloodstream infection (CLABSI) prevention checklist, which has significantly reduced infection rates in various studies^.[28] Bundle sets of evidence-based interventions tend to yield better results than isolated practices.^[29,30]

In ICUs, bundles aimed at preventing ventilator-associated pneumonia (VAP), sepsis, and device-related infections are widely used and have been shown to reduce morbidity and mortality, while improving clinical outcomes.^[26,27,31] The systematization of such protocols fosters a culture of safety and creates a disciplined environment similar to that of an aircraft cockpit, where every action is verified to ensure the standardization of critical processes. Therefore, incorporating checklists and bundles goes beyond formal compliance, and represents a crucial strategy for quality and safety management in ICUs.^[32,33]

The observed reduction in mortality after implementing structured multiprofessional rounds further supports the effectiveness of this practice in improving outcomes, even among high-acuity ICU patients. This may be attributed to the structured interprofessional approach to patient management, which enhances communication and optimizes care delivery.^[1,5,33]

The increase in SAPS 3 scores in the postintervention group might initially be interpreted as a reason for the reduction in mortality, given that the SMR results from the ratio of observed to expected deaths – thus, a higher denominator would imply a lower SMR. However, the consistency of the collected data, along with the shift in the ICU profile following the arrival of an intensivist physician and the implementation of daily rounds, likely contributed to improved safety culture, care management, and overall service quality, which may explain the reduced mortality despite the higher clinical complexity.^[10,30,34]

4.2. Invasive device use and mechanical ventilation duration

The findings of Barcellos and Chatkin (2020), which showed that structured multiprofessional rounds with checklists reduced complications associated with prolonged mechanical ventilation, such as VAP,^[6,12,34] aligned with the results of the current study. We observed a significant reduction in mean IMV duration, suggesting that checklist-guided rounds (Table 1) contributed to earlier ventilator weaning and reduced the risk of complications associated with prolonged respiratory support.

However, the increased use of invasive devices, such as CVCs and IUCs, may reflect the higher severity of patients admitted during the postintervention period. Moderate positive correlations between the SAPS 3 scores and the number of CVC days and CVC use rates, although not significant for IUC, suggest that critically ill patients require invasive support. These findings are consistent with the existing literature, indicating that higher patient severity is often associated with greater dependence on invasive devices for stabilization.^[11,18,35]

4.3. ICU length of stay

No significant reduction in ICU length of stay was observed despite reductions in mortality and IMV duration. This result may be attributed to chronic overcrowding in the hospital where the study was conducted. Even when patients were clinically ready for discharge, the lack of beds in other hospital wards delayed transfer. This issue is common in public hospitals with limited resources and can lead to prolonged ICU stay, reducing the availability of incoming critically ill patients.^[6,12,36]

4.4. Hospital costs

The reduction in IMV duration following the implementation of structured rounds may also have cost-saving implications, which is a critical factor in resource-limited ICUs.^[4,6] Shorter ventilation times are associated with a lower consumption of sedatives, gastric protectors, disposable supplies, and ventilator maintenance. This reduction also correlates with a decreased incidence of VAP, which is linked to higher mortality and longer ICU stays.^[13,34–36]

These findings are consistent with those from high-resource settings, where multiprofessional rounds enhance the already robust technological and pharmacological infrastructure.^[5,35] By contrast, in settings such as those analyzed here, where infrastructure and funding are limited, coordination and optimization of human resources are essential, making structured rounds a critical tool for improving clinical outcomes.

4.5. Regional context

The positive effects of this intervention were particularly relevant in Maranhão, Brazil. Carvalho et al (2019) found that only 43.5% of 23 state ICUs conducted regular rounds, with poorer performance in facilities located outside the capital.^[12,37] Therefore, implementing multiprofessional rounds in these settings is a feasible and necessary strategy for improving clinical outcomes among critically ill patients in public ICUs in Maranhão.

4.6. Experience in other countries

When analyzing similar contexts in other developing countries, such as Brazil and India, some studies investigating the impact of checklists during ICU rounds have not demonstrated significant reductions in mortality rates^.[35] One study conducted in an Indian cohort reported that, despite adherence to evidence-based interventions listed on the ICU checklist, there was a lack of strong evidence for improved clinical outcomes.^[31,35]

Conversely, a large retrospective study conducted in Pennsylvania in 2010 across 112 hospitals and a cohort of 107,324 patients found that daily multidisciplinary rounds were associated with lower ICU mortality (odds ratio [OR], 0.84; 95% confidence interval: 0.76–0.93; P = .001).^[33,35]

Other experiences in developing countries have also confirmed the benefits of multidisciplinary rounds, although implementation is often hindered by structural, cultural, and resource-based barriers.^[13,34,35] Studies in Latin America have shown significant reductions in device-related infections and mortality following the adoption of structured rounds.^[8,34,35] In Brazil, a 2015 study by Soares et al demonstrated that both public and private hospitals implementing daily multidisciplinary rounds experienced up to a 15% reduction in mortality, adjusted for patient severity, even in resource-constrained environments.^[8,34]

4.7. Study limitations

This study has limitations inherent to its retrospective design, including the possibility of bias, and confounding and unmeasured variables that could have influenced the outcomes. Another limitation was the consistent participation of only certain professionals, namely physicians, nurses, physical therapists, nutritionists, pharmacists, and social workers, whereas others were less frequently involved in the rounds. Furthermore, because the study was conducted in a single public ICU, the generalizability is limited. Future studies should adopt prospective and multicenter designs to validate these results and explore the broader applicability of multiprofessional rounds across different settings.

The statistical analysis relied primarily on univariate methods, which limit the ability to control for confounding factors such as comorbidities, case mix, or other concurrent changes in care delivery. The absence of a multivariate model such as logistic regression precludes stronger causal inferences. Although the observed improvements were promising, further research using multivariate and prospective designs is required to confirm these associations.

The main limitations of this study include its retrospective design, potential biases, and limited generalizability as it was conducted in a single public ICU. Although key professionals were consistently present during these rounds, participation of other specialists was infrequent. Future multicenter prospective studies are needed to validate these findings and assess the broader applicability of multiprofessional rounds.

4.8. Practical implications and future research

The implementation of structured multiprofessional rounds in resource-limited ICUs demonstrated promising results, reducing mortality and mechanical ventilation duration, even in the face of increased patient acuity. These findings reinforce the importance of evidence-based management strategies for optimizing critical care.

Clinical practice should incorporate daily structured multiprofessional rounds with validated checklists as a low-cost, high-impact intervention. Ongoing training and active engagement of all team members are crucial for maximizing the effectiveness of this strategy.

Future research should focus on multicenter prospective studies to evaluate the long-term sustainability of outcomes, cost-effectiveness, and the impact on staff and family satisfaction. It is also important to assess the effects of consistent participation from all professional categories and to explore how these practices can be adapted to different institutional and cultural settings.

A key advantage of this intervention is its low costs. Structured rounds require minimal investment and are based primarily on the reorganization of care processes and team engagement without the need for advanced technology or complex infrastructure. This makes the strategy highly scalable to other public ICUs, particularly in low- and middle-income countries, where material and human resource shortages are the norm.

Given the simplicity of the tool and the use of applied management methodologies such as PDCA and standardized checklists, the intervention holds potential for replication and adaptation across diverse healthcare contexts.

The originality of this study lies in its systematic application of quality improvement practices within a severely resource-constrained environment, which is still underrepresented in international literature.^[8] By demonstrating that relatively simple organizational interventions can significantly improve clinical outcomes, the findings contribute to expanding patient safety strategies and supporting the development of public policies aimed at standardizing intensive care in emerging nations.

While the reduction in the SMR and mechanical ventilation duration after the intervention is encouraging, it is important to acknowledge that these findings cannot be interpreted as causal due to the observational design and the absence of multivariate adjustment for baseline differences in patient severity. Further prospective studies with robust risk adjustments are required to confirm these associations.

5. Conclusion

The implementation of daily multiprofessional rounds appears to significantly improve clinical outcomes for ICU patients, even in resource-limited settings. Despite the unchanged length of ICU stay, the observed reduction in mortality and IMV duration underscores the importance of structured interprofessional collaboration in critical care. However, continuous monitoring and protocol revision are necessary to ensure that the benefits of this intervention are not counterbalanced by the increased risks associated with prolonged use of invasive devices.

Acknowledgments

We would like to express our gratitude to the Hospital Municipal Djalma Marques (HMDM) for providing the setting for this study and to the Federal University of Maranhão (UFMA) for their academic support. Our sincere thanks also go to all the healthcare professionals involved in the multiprofessional rounds, whose dedication contributed to the success of this research.

Author contributions

Conceptualization: Hiago Sousa Bastos, Déborah Lydia Oliveira Da Silva, Luciana Sousa Silva, Leonardo Oliveira De Araújo, Vinicius Freire Pereira, Almir Vieira Dibai Filho, João Nogueira Neto, Caio Márcio Barros de Oliveira, Ed Carlos Rey Moura.

Data curation: Hiago Sousa Bastos, Paula De Carvalho Bacelar, Déborah Lydia Oliveira Da Silva, João Marcelo De Jesus Peixoto Lopes, Caroline Marques Nascimento, Yasmin Sousa Bastos, Luciana Sousa Silva, Leonardo Oliveira De Araújo, Vinicius Freire Pereira, Davi Petrus Pereira Martins, William Maciel Mendes Júnior, Valdemiro Freitas Neto.

Formal analysis: Hiago Sousa Bastos, Davi Petrus Pereira Martins, Almir Vieira Dibai Filho, Ed Carlos Rey Moura, Plínio Da Cunha Leal.

Funding acquisition: João Marcelo De Jesus Peixoto Lopes.

Investigation: Hiago Sousa Bastos, João Marcelo De Jesus Peixoto Lopes, Caroline Marques Nascimento, Yasmin Sousa Bastos, Luciana Sousa Silva, Leonardo Oliveira De Araújo, William Maciel Mendes Júnior, Valdemiro Freitas Neto.

Methodology: Hiago Sousa Bastos, Paula De Carvalho Bacelar, Caroline Marques Nascimento, Luciana Sousa Silva, Vinicius Freire Pereira, João Nogueira Neto, Valdemiro Freitas Neto, Plínio Da Cunha Leal.

Project administration: Hiago Sousa Bastos, Yasmin Sousa Bastos, Vinicius Freire Pereira, Ed Carlos Rey Moura.

Resources: Hiago Sousa Bastos.

Software: Hiago Sousa Bastos, Davi Petrus Pereira Martins.

Supervision: Hiago Sousa Bastos, Vinicius Freire Pereira, Almir Vieira Dibai Filho, João Nogueira Neto, Caio Márcio Barros de Oliveira, William Maciel Mendes Júnior, Ed Carlos Rey Moura, Plínio Da Cunha Leal.

Validation: Hiago Sousa Bastos, Almir Vieira Dibai Filho, João Nogueira Neto, Caio Márcio Barros de Oliveira, Plínio Da Cunha Leal.

Visualization: Hiago Sousa Bastos.

Writing – original draft: Hiago Sousa Bastos.

Writing – review & editing: Hiago Sousa Bastos, Plínio Da Cunha Leal.