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Quality improvement model (IHI) as a strategy to implement a sepsis protocol in a public hospital in Brazil
  1. Leidy Katerine Calvo Nates1,
  2. Antônio Capone Neto2,
  3. Adriano José Pereira1,2,3,4,
  4. Eliézer Silva1,2
  5. On behalf of the Participant
    1. 1Postgraduate School of Health Sciences, Sociedade Beneficente Israelita Brasileira Hospital Albert Einstein, São Paulo, São Paulo, Brazil
    2. 2Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
    3. 3Hospital Municipal da Vila Santa Catarina, São Paulo, SP, Brazil
    4. 4Associated Researcher of the Postgraduate Program of Health Sciences, Universidade Federal de Lavras, MG, Brazil
    1. Correspondence to Dr Leidy Katerine Calvo Nates; lykatina85{at}


    A major challenge for hospitals in low-income and middle-income countries is to improve management of patients diagnosed with sepsis. The objective of the present study was to evaluate the Institute for Healthcare Improvement (IHI) Model as a strategy to implement a managed sepsis protocol aimed at reducing sepsis mortality. We performed a longitudinal, prospective, non-randomised study using PDSA cycles for translating and implementing improvement actions and tools. Baseline case mortality/case fatality data were collected, and compliance rates were evaluated according to the Surviving Sepsis Campaign guidelines (3-hour care-bundle). Sepsis multidisciplinary work teams were designated and were responsible to develop Driver Diagrams and implement process changes in the intensive care unit, wards and emergency department. Satisfaction levels of healthcare professionals were assessed (balance variables). The study was carried out in a public quaternary hospital, in São Paulo city, Brazil (Hospital Municipal da Vila Santa Catarina). The number of patients with sepsis studied was 416 who were followed over a 15-month period. The data analyses were carried out by statistical process control. Case fatality rates were kept below a prespecified target of 25% (15.9%) during the period. Satisfaction level of the participating staff was high (95.2%) and 71% of participants reported no work overload. The IHI model was found to be a feasible and useful strategy for implementing a sepsis management clinical protocol.

    • clinical practice guidelines
    • implementation science
    • patient safety
    • quality improvement methodologies
    • PDSA

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    • Collaborators We would like to acknowledge the sepsis multidisciplinary work teams: Guilherme de Paula Pinto Schettino, MD, PhD (Medical director); Ana Paula Metran Nascente Pereira, MD, PhD (ICU Department); Adolfo Wenjaw Liao, MD, PhD (Obstetrics Department); Midgley Gonzales, MD, PhD (Obstetrics Department); Monica Andrade de Carvalho, MD, MSc, MBA (ICU Department); Rosana Mandelbaum, MD (Clinician, Rapid Response Team); Fernanda Domingos Giglio Petreche, MD (Clinician, Rapid Response Team); Cristina Tiemi Amadatsu, MD (Obstetrics Department); Carolina Devite Bittante, MD (Infection Control); Leonardo Jose Rolim Ferraz, MD (Medical Manager); Carlos Alberto Eduardo Gomes, MD (Medical Manager Municipal Emergency Unit) ; Rodrigo Vone Fregoneze, MD (Medical Coordinator Municipal Emergency Unit); Rodrigo NG Taniguchi MD (Municipal Emergency Unit Attending Physician); Gabriela Sato, MBA (Hospital Manager); Marcia Galluci Pinter, MSc (Surgical Unit Coordinator); Adriana Martins da Silva, MBA (Wards Coordinator); Maitê Augusta C. C. Rossetto (Quality Coordinator); Eliton Paulo Leite Lourenco, MBA (Head of ICU Nurses); Samira Scalso de Almeida (Imaging Department); Silvana Aparecida Eleodoro dos Santos (Obstetric Coordinator); Marcelo Longarezi Valvassora, MSc (Transplant Department Nurse); Maria Aparecida Machado (Oncology Nurse); Caroline Gusmão Alves Santos (Wards Nurse); Camila de Carvalho Gambin (ICU Nurse); Natalia Nunez de Souza (ICU Nurse); Priscilla Santini Ramalho (Wards Nurse); Érika Brosco Lima (Obstetric Department Nurse); Maria Caroline de Oliveira (Obstetric Department Nurse); Andreza Moreira Santana (Emergency Nurse); Andreza Michele Secolo (Emergency Nurse); Denise Simas Lamarão, MBA (Pharmacist); Francisco Neves Pereira (Lab Coordinator); Ana Paula Doria Santos (Emergency Nurse); Claudia Regina Basilio Foglietto (Emergency Nurse); Priscila Reimão de Melo Fortunato (Wards Nurse); Ernane Cruz da Silva (Medical Records Department); and Ana Paula de Oliveira Ribeiro (Medical Records Department).

    • Contributors ES and AJP conceived the study. All authors and coauthors contributed to the planning. LKCN and AJP led the MWTs in producing the study tools. LKCN carried out the PDSA cycles. LKCN and AC were responsible for the results and analysis, and LKCN was responsible for its submission. All authors have participated in writing, revising, correcting and editing the manuscript.

    • Funding LKCN was funded by a master's studentship from the Brazilian Ministry of Education (CAPES). The study was conducted in partnership with the Brazilian Ministry of Health through the Institutional Development Program of the Unified Health System (PROADI - SUS), and classified as one of the objectives of the National Health Plan, highlighting the relevance and potential contribution of the project to the governance of the SUS, according to the ordinance 3.362, 12/8/2017.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval The Research Ethics Committees of the Hospital Israelita Albert Einstein and the Municipal Health Department approved this study.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available. All data relevant to the study are included in the article or uploaded as supplementary information. We can only share data without the identification of audited patients, only tables.

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