title: Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study.
abstract: OBJECTIVE
  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.
authors.affiliation: Unidade de Terapia Intensiva, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo, SP, 01321-001, Brazil.
authors.forename: Danilo Teixeira
authors.initials: DT
authors.lastname: Noritomi
authors.affiliation: Unidade de Terapia Intensiva, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo, SP, 01321-001, Brazil. otavioranzani@yahoo.com.br.|Unidade de Terapia Intensiva, Disciplina de Emergências Clínicas, Hospital das Clínicas, Universidade de São Paulo, Rua Enéas Carvalho de Aguiar, 255, sala 6040, 6° andar, São Paulo, 05403-000, Brazil. otavioranzani@yahoo.com.br.
authors.forename: Otavio T
authors.initials: OT
authors.lastname: Ranzani
authors.affiliation: Unidade de Terapia Intensiva, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo, SP, 01321-001, Brazil.
authors.forename: Mariana Barbosa
authors.initials: MB
authors.lastname: Monteiro
authors.affiliation: Latin America Sepsis Institute, Rua Pedro de Toledo n° 980 cj. 94, São Paulo, 04039-002, Brazil.
authors.forename: Elaine Maria
authors.initials: EM
authors.lastname: Ferreira
authors.affiliation: Unidade de Terapia Intensiva, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo, SP, 01321-001, Brazil.
authors.forename: Sergio Ricardo
authors.initials: SR
authors.lastname: Santos
authors.affiliation: Unidade de Terapia Intensiva, Hospital Paulistano, Rua Martiniano de Carvalho, 741, São Paulo, SP, 01321-001, Brazil.
authors.forename: Fernando
authors.initials: F
authors.lastname: Leibel
authors.affiliation: Latin America Sepsis Institute, Rua Pedro de Toledo n° 980 cj. 94, São Paulo, 04039-002, Brazil.|Disciplina de Anestesiologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715, 5° andar, São Paulo, 04024-900, Brazil.
authors.forename: Flavia Ribeiro
authors.initials: FR
authors.lastname: Machado
mesh_terms: D001938:Brazil; D003362:Cost-Benefit Analysis; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006282:Health Personnel / Q000193:education*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012151:Resuscitation / Q000191:economics / Q000193:education* / Q000592:standards*; D012189:Retrospective Studies; D018805:Sepsis / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome