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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*

Machado, Flavia R. MD, PhD; Ferreira, Elaine M. MSc, RN; Sousa, Juliana Lubarino RN; Silva, Carla RN; Schippers, Pierre MD; Pereira, Adriano MD, PhD; Cardoso, Ilusca M. MD, MSc; Salomão, Reinaldo MD, PhD; Japiassu, Andre MD, PhD; Akamine, Nelson MD, MSc; Mazza, Bruno F. MD, MSc; Assunção, Murillo S. C. MD, MSc; Fernandes, Haggeas S. MD; Bossa, Aline MSc; Monteiro, Mariana B. RN; Caixeita, Noemi; Azevedo, Luciano C. P. MD, PhD; Silva, Eliezer MD, PhD; on behalf of the Latin American Sepsis Institute Network

doi: 10.1097/CCM.0000000000002585
Clinical Investigations
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Objective: We aimed to assess the results of a quality improvement initiative in sepsis in an emerging setting and to analyze it according to the institutions’ main source of income (public or private).

Design: Retrospective analysis of the Latin American Sepsis Institute database from 2005 to 2014.

Settings: Brazilian public and private institutions.

Patients: Patients with sepsis admitted in the participant institutions.

Interventions: The quality improvement initiative was based on a multifaceted intervention. The institutions were instructed to collect data on 6-hour bundle compliance and outcomes in patients with sepsis in all hospital settings. Outcomes and compliance was measured for eight periods of 6 months each, starting at the time of the enrollment in the intervention. The primary outcomes were hospital mortality and compliance with 6-hour bundle.

Measurements and Main Results: We included 21,103 patients; 9,032 from public institutions and 12,071 from private institutions. Comparing the first period with the eigth period, compliance with the 6-hour bundle increased from 13.5% to 58.2% in the private institutions (p < 0.0001) and from 7.4% to 15.7% in the public institutions (p < 0.0001). Mortality rates significantly decreased throughout the program in private institutions, from 47.6% to 27.2% in the eighth period (adjusted odds ratio, 0.45; 95% CI, 0.32–0.64). However, in the public hospitals, mortality diminished significantly only in the first two periods.

Conclusion: 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.

*See also p. 1783.

All authors: Latin American Sepsis Institute, São Paulo, Brazil.

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Supported, in part, by the Latin American Sepsis Institute (LASI). Until 2009, the Latin America Sepsis Institute received unrestricted grants from Eli Lilly do Brasil, Fresenius Kabi, Pfizer, and Merck Sharp Dohme. Since 2010, no industry grants have been received directly by the LASI.

Dr. Machado had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis and assumes full responsibility for the integrity of the submission as a whole, from inception to the published article. Dr. Machado, Ms. Ferreira, Ms. Sousa, Ms. C. Silva, Drs. Schippers, Pereira, Cardoso, Salomão, Akamine, Mazza, Assunção, Fernandes, Azevedo, and E. Silva contributed substantially to the implementation process, data analysis and interpretation, and the writing of the article.

The authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: frmachado@unifesp.br

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