BackgroundPublic hospitals in emerging countries pose a challenge to quality improvement initiatives in sepsis. Our objective was to evaluate the results of a quality improvement initiative in sepsis in a network of public institutions and to assess potential differences between institutions that did or did not achieve a reduction in mortality.MethodsWe conducted a prospective study of patients with sepsis or septic shock. We collected baseline data on compliance with the Surviving Sepsis Campaign 6-h bundles and mortality. Afterward, we initiated a multifaceted quality improvement initiative for patients with sepsis or septic shock in all hospital sectors. The primary outcome was hospital mortality over time. The secondary outcomes were the time to sepsis diagnosis and compliance with the entire 6-h bundles throughout the intervention. We defined successful institutions as those where the mortality rates decreased significantly over time, using a logistic regression model. We analyzed differences over time in the secondary outcomes by comparing the successful institutions with the nonsuccessful ones. We assessed the predictors of in-hospital mortality using logistic regression models. All tests were two-sided, and a p value less than 0.05 indicated statistical significance.ResultsWe included 3435 patients from the emergency departments (50.7%), wards (34.1%), and intensive care units (15.2%) of 9 institutions. Throughout the intervention, there was an overall reduction in the risk of death, in the proportion of septic shock, and the time to sepsis diagnosis, as well as an improvement in compliance with the 6-h bundle. The time to sepsis diagnosis, but not the compliance with bundles, was associated with a reduction in the risk of death. However, there was a significant reduction in mortality in only two institutions. The reduction in the time to sepsis diagnosis was greater in the successful institutions. By contrast, the nonsuccessful sites had a greater increase in compliance with the 6-h bundle.ConclusionsQuality improvement initiatives reduced sepsis mortality in public Brazilian institutions, although not in all of them. Early recognition seems to be a more relevant factor than compliance with the 6-h bundle.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1858-z) contains supplementary material, which is available to authorized users.

This quality improvement initiative in sepsis in an emerging country was associated with a reduction in mortality and with improved compliance with quality indicators. However, this reduction was sustained only in private institutions.

No abstract

IntrPrevious studies already showed a reduction in sepsis' mortality rates after the implementation of protocols based on the Surviving Sepsis Campaign (SSC) bundles, in high income countries. However, there is no similar study in emerging szettings. ObjectivesTo assess the impact of a national initiative in implementing sepsis protocols in Brazilian institutions, analyzing them according to the source of income (public or private). MethodsRetrospective analysis of the Latin America Sepsis Institute (LASI) database, from 2005 to 2014. Participation was voluntary. The implementation process was based on a multifaceted intervention including a local sepsis team, protocols, screening procedures, laboratory and antibiotics flowchart for emergency department (ED), wards and intensive care units (ICU), checklists, physicians and nurses training nd audit/feedback strategies. After the initial training, the institutions collect data on SSC bundles compliance and hospital outcome in patients with severe sepsis or septic shock in all hospital settings. We included only the institutions with at least 80 patients and at least one year of data collection, excluding patients admitted after the first four years of the campaign. All patients were followed until hospital discharge. We define public institutions as those with the major income coming from public sources and private as those coming from private insurances. ResultsWe included 21,103 patients from 65 institutions being 9,032 from public institutions and 12,071 from private ones. Comparing the 1 st semester with the 8 th semester, compliance with the 6-hours bundle increased from 13.5% to 58.2% in the private institutions while the public ones improved from 7.4% to 15.7%. Mortality rates significantly decreased throughout the program in private institutions (1st semester: 47.6%, 8 th semester: 27.2%; odds ratio (OR): 0.45; 95% confidence interval (CI): 0.32-0.64). However, there is no significant reduction in the public institutions throughout the semesters (1 st semester: 61.3%; 8 th semester: 54.5%, OR: 0.63; 95%CI: 0.39-1.02). The intervention reduced the mortality rates throughout the semesters in patients from all settings (1 st semester vs 8 th semester: ED -OR: 0.55; 95%CI: 0.38 -0.79; wards -OR: 0.59; 95%CI: 0.42-0.83; ICU -OR: 0.46; 95%CI: 0.39 -0.54) although the effect was less consistent in the ICU. In patients from private ED, mortality rates decreased from 38.1 to 21.2% (p < 0.001) while in the public institutions this reduction was not significant (56.3% to 49.8%, p = 0.057). ConclusionsThe implementation of sepsis protocols resulted in improved compliance to the quality indicators and reduction in mortality rates.