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Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study

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Abstract

Purpose

To evaluate whether a multifaceted, centrally coordinated quality improvement program in a network of hospitals can increase compliance with the resuscitation bundle and improve clinical and economic outcomes in an emerging country setting.

Methods

This was a pre- and post-intervention study in ten private hospitals (1,650 beds) in Brazil (from May 2010 to January 2012), enrolling 2,120 patients with severe sepsis or septic shock. The program used a multifaceted approach: screening strategies, multidisciplinary educational sessions, case management, and continuous performance assessment. The network administration and an external consultant provided performance feedback and benchmarking within the network. The primary outcome was compliance with the resuscitation bundle. The secondary outcomes were hospital mortality, hospital and ICU length of stay, quality-adjusted life year (QALY) gain, and cost-effectiveness.

Results

The proportion of patients who received all the required items for the resuscitation bundle improved from 13 % [95 % confidence interval (CI) 8–18 %] at baseline to 62 % (95 % CI 54–69 %) in the last trimester (p < 0.001). Hospital mortality decreased from 55 % (95 % CI 48–62 %) to 26 % (95 % CI 19–32 %, p < 0.001). Full compliance with the resuscitation bundle was associated with lower risk of hospital mortality (propensity weighted corrected risk ratio 0.74; 95 % CI 0.56–0.94, p = 0.02). There was a reduction in the total cost per patient from 29.3 (95 % CI 23.9–35.4) to 17.5 (95 % CI 14.3–21.1) thousand US dollars from baseline to the last 3 months (mean difference −11,815; 95 % CI −18,604 to −5,338). The mean QALY increased from 2.63 (95 % CI 2.15–3.14) to 4.06 (95 % CI 3.58–4.57). For each QALY, the full compliance saves US$5,383.

Conclusions

A multifaceted approach to severe sepsis and septic shock patients in an emerging country setting led to high compliance with the resuscitation bundle. The intervention was cost-effective and associated with a reduction in mortality.

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Acknowledgments

We thank all study coordinators and case managers from the participating hospitals: Hospital ABC Cirúrgico, Santo André (Alessandra Rosa Tavares; Claudia Benevides; Luciane Marques Bertoldo Viñas; and Ricardo Seiler); Hospital Alvorada Moema, São Paulo (Alfonso Migliore Neto; Bruno F Mazza; Ceu Cordeiro G. Moura; Gisele da Silva Oliveira; and Heloisa Moreira); Hospital da Luz Santo Amaro, São Paulo (Alexandra Silva; Bruno Toldo; Helenice Maida; and Tomi Uchida Lovet); Hospital e Maternidade Ipiranga, Mogi das Cruzes (Manuel Leitão Neto; Marjorie Tamaki Mori; Tania Aparecida Machado; and Vinicius Ferreira Rocha); Hospital da Luz Vila Mariana, São Paulo (Heraldo Jesus; Jose Luiz Cunha Carneiro Junior; Roseane Fernandes Romualdo; and Sylas Bezerra Cappi); Hospital Metropolitano Butantã, São Paulo (Antonio Claudomiro A. Beneventti; Masao Murata; Oswaldo Americo C. de Oliveira; and Silza Tamar dos Santos de Andrade); Hospital Metropolitano Lapa, São Paulo (Ana Maria Cristina B. Sogayar; Darcy Lisbão Moreira de Carvalho; Janaína Silva; and Maria Claudia Dalaneze Gomes); Hospital Paulistano, São Paulo (Danilo Teixeira Noritomi; Marcio J. C. Arruda; Marco Antonio G. Baroni; and Mariana Barbosa Monteiro); Hospital TotalCor, São Paulo (Antonio Claudio do Amaral Baruzzi; Damiana Vieira dos Santos Rinaldi; and Valter Furlan); Hospital Vitória, São Paulo (Luiz Cervone; Paulo Sergio de Andrade Rehder; Pedro Fausto; Priscila Salvador Baptista; and Ricardo Goulart Rodrigues). We thank Pierre Schippers (Latin America Sepsis Institute) for the development of the software used to collect data and Ilusca Cardoso de Paula (Latin America Sepsis Institute) for her help with the hospital performance reports. We would like thank Lucas Fahham and Vanessa Teich for their help with the statistics. We would like to thank the Research and Education Institute, Rede Amil, São Paulo, Brazil. Finally, we would like to thank Nelson Akamine for his fundamental contribution in the beginning of the initiative.

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The authors have no conflict of interest.

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Correspondence to Otavio T. Ranzani.

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On behalf of the AMIL Critical Care Group.

Take-home message: A multifaceted approach, with a centralized network administration, an external consultant, and benchmarking within the network, is an efficient way to improve sepsis care. Indeed, the high compliance was associated with low mortality rate and was cost-saving. Our study has shown that, in an emerging country setting, compliance with the Surviving Sepsis Campaign (SSC) resuscitation bundle is associated with improvement in mortality even when adjusted for disease severity or propensity to achieve the resuscitation goals.

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Noritomi, D.T., Ranzani, O.T., Monteiro, M.B. et al. Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study. Intensive Care Med 40, 182–191 (2014). https://doi.org/10.1007/s00134-013-3131-5

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