Quality Improvement Initiatives in Sepsis in an Emerging Country: Does the Institution’s Main Source of Income Influence the Results? An Analysis of 21,103 Patients*

Machado, Flávia Ribeiro; Ferreira, Elaine Maria; Sousa, Juliana Lubarino; Silva, Carla; Schippers, Pierre; Pereira, A L; Cardoso, Ilusca M; Salomão, Reinaldo; Japiassú, André Miguel; Akamine, Nelson; Mazza, Bruno Franco; Assunção, Murillo Santucci César de; Fernandes, Haggeas S; Bossa, Aline Siqueira; Monteiro, Mariana B; Caixeita, Noemi; Azevedo, Luciano César Pontes; Silva, Eliezer

doi:10.1097/ccm.0000000000002585

Cited by 24 publications

(18 citation statements)

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“…Although data from resource-limited settings are scarce, mortality reduction is not a consistent or sustained finding [ 15 , 18 , 31 ]. Our findings support this heterogeneity because only two institutions reduced their mortality rates despite the consistent global improvement in other quality indicators.…”

Section: Discussionmentioning

confidence: 99%

“…On the basis of our previous experience with the quality improvement program in the LASI [ 18 ], we expected that the mortality rates would not decrease in some institutions. Thus, we defined successful institutions as those where the mortality rates decreased significantly over time, and those in which the mortality rates did not drop were defined as nonsuccessful institutions.…”

Section: Methodsmentioning

confidence: 99%

“…Quality improvement initiatives are successful in reducing fatality rates in high-income countries [ 9 ], but there are only a few reports of such initiatives in LMICs [ 10 – 15 ]. In Brazil, some studies have already shown higher mortality rates in public institutions than in private ones [ 16 , 17 ]; also, public institutions have worse compliance with treatment quality indicators, and mortality reductions in quality improvement initiatives seem not to be sustained [ 16 , 18 ].…”

Section: Introductionmentioning

confidence: 99%

“…Therefore, we aimed to assess whether a quality improvement initiative in a network of public hospitals in Brazil would decrease mortality and the factors that would be associated with this reduction. On the basis of our previous experience in public hospitals [ 18 ], we anticipated that the success of the initiative would be heterogeneous among the hospitals; therefore, our secondary objective was to identify the quality indicators associated with a reduction in mortality rates.…”

Section: Introductionmentioning

confidence: 99%

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Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results

et al. 2017

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results

et al. 2017

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“…Jorge I. F. Salluh 1,2* , Thiago Lisboa 3,4 and Fernando A. Bozza 1,5 Background The delivery of critical care is a major challenge for developing countries [1]. The inequity of access to an ICU bed, heterogeneous triage policies, a low staff/patient ratio and suboptimal adherence to evidence-based practices contribute to disproportionally high mortality of sepsis and acute respiratory distress syndrome in these countries [2][3][4][5]. In addition, limited step-down and specialized ward beds' availability further widens the gap between critical and non-critical care inside hospitals.…”

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confidence: 99%

Challenges for the care delivery for critically ill COVID-19 patients in developing countries: the Brazilian perspective

2020

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Sepsis in Low- and Middle-Income Countries

Azevedo

Machado

2018

Handbook of Sepsis

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Quality Improvement Initiatives in Sepsis in an Emerging Country: Does the Institution’s Main Source of Income Influence the Results? An Analysis of 21,103 Patients*

Abstract: 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.

Cited by 24 publications

References 45 publications

Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results

Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results

Challenges for the care delivery for critically ill COVID-19 patients in developing countries: the Brazilian perspective

Sepsis in Low- and Middle-Income Countries

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