Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results.

BACKGROUND: Public hospitals in emerging countries pose a challenge to quality improvement initiatives in sepsis. Our objective was to evaluate the results of a quality improvement initiative in sepsis in a network of public institutions and to assess potential differences between institutions that did or did not achieve a reduction in mortality. METHODS: We conducted a prospective study of patients with sepsis or septic shock. We collected baseline data on compliance with the Surviving Sepsis Campaign 6-h bundles and mortality. Afterward, we initiated a multifaceted quality improvement initiative for patients with sepsis or septic shock in all hospital sectors. The primary outcome was hospital mortality over time. The secondary outcomes were the time to sepsis diagnosis and compliance with the entire 6-h bundles throughout the intervention. We defined successful institutions as those where the mortality rates decreased significantly over time, using a logistic regression model. We analyzed differences over time in the secondary outcomes by comparing the successful institutions with the nonsuccessful ones. We assessed the predictors of in-hospital mortality using logistic regression models. All tests were two-sided, and a p value less than 0.05 indicated statistical significance. RESULTS: We included 3435 patients from the emergency departments (50.7%), wards (34.1%), and intensive care units (15.2%) of 9 institutions. Throughout the intervention, there was an overall reduction in the risk of death, in the proportion of septic shock, and the time to sepsis diagnosis, as well as an improvement in compliance with the 6-h bundle. The time to sepsis diagnosis, but not the compliance with bundles, was associated with a reduction in the risk of death. However, there was a significant reduction in mortality in only two institutions. The reduction in the time to sepsis diagnosis was greater in the successful institutions. By contrast, the nonsuccessful sites had a greater increase in compliance with the 6-h bundle. CONCLUSIONS: Quality improvement initiatives reduced sepsis mortality in public Brazilian institutions, although not in all of them. Early recognition seems to be a more relevant factor than compliance with the 6-h bundle.

Characteristics and clinical outcomes of COVID-19 in children: a hospital-based surveillance study in Latin America's hardest-hit city.

Background: In 2020, Brazil became the epicentre of the coronavirus disease (COVID-19) pandemic in Latin America, resulting in an unparalleled health catastrophe. Nevertheless, comprehensive clinical reports in Brazilian children are not available. Methods: This retrospective, hospital-based, active surveillance study was performed to identify paediatric patients with COVID-19 who presented at a private academic medical centre in a large urban area between March 2020 and March 2021. Clinical and demographic information was analysed for those requiring hospitalization, those with severe illness and those with clinical syndromes. Results: In total, 964 symptomatic cases were evaluated; of these, 17.7% required hospitalization, and 27.5% of hospitalized cases were classified as severe/critical. Acute bronchiolitis and pneumonia were the most common causes of hospitalization among the severe cases. Twenty-seven hospitalized children fulfilled the diagnostic criteria for multi-system inflammatory syndrome (median age 29 months; 85.2% cases were non-severe). A significant co-existing condition was present in 29% of hospitalized children. The risk of hospitalization was higher in children with at least one comorbidity, children aged <2 years and obese children. Increased risk of severe disease was described among those with leukopenia, leukocytosis or any significant comorbidity. No deaths occurred among the study population. Conclusion: Although most children with COVID-19 experienced mild disease, and no deaths occurred among the study population, a significant proportion of cases required hospitalization and developed severe illness. Obesity, young age, underlying comorbidity, leukopenia and leukocytosis were risk factors for hospitalization or severe disease.

Telemonitoring of Children with COVID-19: Experience Report of the First 100 Cases.

Introduction: The first case of coronavirus disease 2019 (COVID-19) in Brazil was diagnosed in February 2020. On March 20, the Ministry of Health issued Ordinance no. 467, regulating the use of telemedicine during the pandemic period. One of the various modalities of telemedicine is telemonitoring. Objective: To report our experience with telemonitoring and evaluate its applicability in the follow-up of the first 100 children who received the diagnosis of COVID-19 after visiting the emergency department of Sabará Hospital Infantil ("Hospital Sabará") and who had no indications for hospitalization. Methods: The care records of the children were retrospectively analyzed, and telephone contact with the families of patients who did not complete the proposed telemonitoring protocol was initiated. Results: The average age of the children was 5.5 years, and a slight male predominance (54/100) was observed. Comorbidities were present in 24/100. The source of infection was family members living in the same household in 88/100 and other sources in 12/100. In the first telemonitoring, 44% of the evaluated patients were asymptomatic. In the second telemonitoring, 81% of the patients were asymptomatic. Telemonitoring was completed by 70% of the children. A total of 14 children returned to the emergency department, 11 of whom spontaneously (2/11 were admitted) and 3 under the indication of telemedicine (3/3 were admitted). Conclusions: Telemonitoring proved to be a clinically valuable resource in the follow-up of children with COVID-19, as it allowed continuity of care and identified patients with indications to return to the emergency department of Hospital Sabará and for hospitalization, thus avoiding unnecessary emergency department visits.