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Improving performance and outcome (mortality) after implementation of a change-bundle approach for management of septic patients

Author(s): Adriano José Pereira | Constantino José Fernandes Jr. | Alexandre Gonçalves de Sousa | Nelson Akamine | Gisele de Paula Dias Santos | Adriana Serra Cypriano | Camila Sardenberg | Luís Fernando Lisboa | Eliézer Silva

Journal: Einstein
ISSN 1679-4508

Volume: 6;
Issue: 4;
Start page: 395;
Date: 2008;
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Keywords: Sepsis/therapy | Shock | septic/therapy | Clinical protocols | Mortality | Intensive care | Quality indicators | health care

Objective: Despite the existence of evidence-based guidelines forthe management of patients with severe sepsis and septic shock,there is much variation among individual treatments. Methods: Abefore-after study with prospective data collection was performedat the emergency department and intensive care unit of a 485-bed,private, tertiary, general hospital. A total of 160 patients were enrolled(94 in a “pre-protocol phase” and 66 in a “post-protocol phase”). Aresuscitation bundle for the first six hours and a management bundlefor 24 hours were used. Additional quality indicators were alsoproposed and evaluated. The outcomes analyzed included hospitalmortality, hospital and intensive care unit length of stay, compliancewith bundles and performance related to quality indicators. Results:From the “pre-protocol” to “post-protocol” phase, the diagnosismoved from the intensive care unit (52.0 to 18.2%) to the emergencydepartment (26.6 to 40.9%) and to the wards (17.0 to 36.4%).Number of blood cultures prior to antibiotics, administration ofactivated drotrecogin alfa, use of corticosteroids and compliancewith six-hour and 24-hour sepsis bundles were significantly higherafter protocol implementation. Patients in the “post-protocol” grouphad a statistically lower risk of in-hospital mortality (56.4 versus36.4%, p = 0.01). The greatest decrease in mortality rate occurredamong the most critically ill patients (67.7 to 40.7%, p = 0.004).Conclusions: Adopting an institutional protocol focused on behavioralchanges and using quality improvement tools led to reduced hospitalmortality and generated changes in healthcare team practice. Thisresult adds to the growing evidence that optimized process-of-careby implementing managed protocols for sepsis patients can reducemortality. Therefore, similar strategies should be routinely employed.
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