Effectiveness of a sepsis programme in a resource-limited setting: a retrospective analysis of data of a prospective observational study (Ubon-sepsis)

Suchart Booraphun, Viriya Hantrakun, Suwatthiya Siriboon, Chaiyaporn Boonsri, Pulyamon Poomthong, Bung-Orn Singkaew, Oratai Wasombat, Parinya Chamnan, Ratapum Champunot, Kristina Rudd, Nicholas P J Day, Arjen M Dondorp, Prapit Teparrukkul, Timothy Eoin West, Direk Limmathurotsakul, Suchart Booraphun, Viriya Hantrakun, Suwatthiya Siriboon, Chaiyaporn Boonsri, Pulyamon Poomthong, Bung-Orn Singkaew, Oratai Wasombat, Parinya Chamnan, Ratapum Champunot, Kristina Rudd, Nicholas P J Day, Arjen M Dondorp, Prapit Teparrukkul, Timothy Eoin West, Direk Limmathurotsakul

Abstract

Objective: To evaluate the effectiveness of a Sepsis Fast Track (SFT) programme initiated at a regional referral hospital in Thailand in January 2015.

Design: A retrospective analysis using the data of a prospective observational study (Ubon-sepsis) from March 2013 to January 2017.

Setting: General medical wards and medical intensive care units (ICUs) of a study hospital.

Participants: Patients with community-acquired sepsis observed under the Ubon-sepsis cohort. Sepsis was defined as modified Sequential Organ Failure Assessment (SOFA) Score ≥2.

Main exposure: The SFT programme was a protocol to identify and initiate sepsis care on hospital admission, implemented at the study hospital in 2015. Patients in the SFT programme were admitted directly to the ICUs when available. The non-exposed group comprised of patients who received standard of care.

Main outcome: The primary outcome was 28-day mortality. The secondary outcomes were measured sepsis management interventions.

Results: Of 3806 sepsis patients, 903 (24%) were detected and enrolled in the SFT programme of the study hospital (SFT group) and 2903 received standard of care (non-exposed group). Patients in the SFT group had more organ dysfunction, were more likely to receive measured sepsis management and to be admitted directly to the ICU (19% vs 4%). Patients in the SFT group were more likely to survive (adjusted HR 0.72, 95% CI 0.58 to 0.88, p=0.001) adjusted for admission year, gender, age, comorbidities, modified SOFA Score and direct admission to the ICUs.

Conclusions: The SFT programme is associated with improved sepsis care and lower risk of death in sepsis patients in rural Thailand, where some critical care resources are limited. The survival benefit is observed even when all patients enrolled in the programme could not be admitted directly into the ICUs.

Trial registration number: NCT02217592.

Keywords: epidemiology; infectious diseases; intensive & critical care.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.

Figures

Figure 1
Figure 1
Flow of participants through study. This study used the data of an observational study on sepsis patients (Ubon-sepsis) from March 2013 to January 2017 to evaluate the effectiveness of a Sepsis Fast Track (SFT) programme implemented at the study hospital in January 2015. SOFA, Sequential Organ Failure Assessment.
Figure 2
Figure 2
(A) Unadjusted probability of survival and (B) adjusted probability of survival based on the multivariable Cox proportional hazard regression model.

References

    1. Singer M, Deutschman CS, Seymour CW, et al. . The third International consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315:801–10. 10.1001/jama.2016.0287
    1. Rhodes A, Evans LE, Alhazzani W, et al. . Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med 2017;45:486–552. 10.1097/CCM.0000000000002255
    1. WHO WHO sepsis technical expert meeting - meeting report Geneva: World Health Organization, 2018. Available: [Accessed 25 Nov 2019].
    1. Vincent J-L The clinical challenge of sepsis identification and monitoring. PLoS Med 2016;13:e1002022. 10.1371/journal.pmed.1002022
    1. Rudd KE, Johnson SC, Agesa KM. Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the global burden of disease study. The Lancet 2020;395:200–11.
    1. Reinhart K, Daniels R, Kissoon N, et al. . Recognizing sepsis as a global health priority - a WHO resolution. N Engl J Med 2017;377:414–7. 10.1056/NEJMp1707170
    1. Kwizera A, Baelani I, Mer M, et al. . The long sepsis journey in low- and middle-income countries begins with a first step but on which road? Crit Care 2018;22:64. 10.1186/s13054-018-1987-z
    1. McGloughlin S, Richards GA, Nor MBM, et al. . Sepsis in tropical regions: report from the task force on tropical diseases by the world Federation of societies of intensive and critical care medicine. J Crit Care 2018;46:115–8. 10.1016/j.jcrc.2017.12.018
    1. Becker JU, Theodosis C, Jacob ST, et al. . Surviving sepsis in low-income and middle-income countries: new directions for care and research. Lancet Infect Dis 2009;9:577–82. 10.1016/S1473-3099(09)70135-5
    1. Schultz MJ, Dunser MW, Dondorp AM, et al. . Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future. Intensive Care Med 2017;43:612–24. 10.1007/s00134-017-4750-z
    1. Dellinger RP, Levy MM, Rhodes A, et al. . Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013;39:165–228. 10.1007/s00134-012-2769-8
    1. Bureau of Inspection and Evaluation, Ministry of Public Health, Thailand Inspection guideline for the fiscal year 2018, 2017. Available: [Accessed 24 May 2019].
    1. Ruangchan S, Chusri S, Saengsanga P, et al. . Clinical outcomes of community-acquired severe sepsis after implementation of a simple severe sepsis fast track. J Med Assoc Thai 2016;99:877–85.
    1. Ittisanyakorn M, Ruchichanantakul S, Vanichkulbodee A, et al. . Prevalence and factors associated with one-year mortality of infectious diseases among elderly emergency department patients in a middle-income country. BMC Infect Dis 2019;19:662. 10.1186/s12879-019-4301-z
    1. Clarke GM, Conti S, Wolters AT, et al. . Evaluating the impact of healthcare interventions using routine data. BMJ 2019;365:l2239. 10.1136/bmj.l2239
    1. Hantrakun V, Somayaji R, Teparrukkul P, et al. . Clinical epidemiology and outcomes of community acquired infection and sepsis among hospitalized patients in a resource limited setting in northeast Thailand: a prospective observational study (Ubon-sepsis). PLoS One 2018;13:e0204509. 10.1371/journal.pone.0204509
    1. Rudd KE, Hantrakun V, Somayaji R, et al. . Early management of sepsis in medical patients in rural Thailand: a single-center prospective observational study. J Intensive Care 2019;7:55. 10.1186/s40560-019-0407-z
    1. Seymour CW, Liu VX, Iwashyna TJ, et al. . Assessment of clinical criteria for sepsis: for the third International consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315:762. 10.1001/jama.2016.0288
    1. Craig P, Cooper C, Gunnell D, et al. . Using natural experiments to evaluate population health interventions: new medical Research Council guidance. J Epidemiol Community Health 2012;66:1182–6. 10.1136/jech-2011-200375
    1. Westreich D, Greenland S. The table 2 fallacy: presenting and interpreting confounder and modifier coefficients. Am J Epidemiol 2013;177:292–8. 10.1093/aje/kws412
    1. Teparrukkul P, Hantrakun V, Imwong M, et al. . Utility of qSOFA and modified SOFA in severe malaria presenting as sepsis. PLoS One 2019;14:e0223457. 10.1371/journal.pone.0223457
    1. Teparrukkul P, Hantrakun V, Day NPJ, et al. . Management and outcomes of severe dengue patients presenting with sepsis in a tropical country. PLoS One 2017;12:e0176233. 10.1371/journal.pone.0176233
    1. Pierson DJ Indications for mechanical ventilation in adults with acute respiratory failure. Respir Care 2002;47:249–62.
    1. Pham T, Brochard LJ, Slutsky AS. Mechanical ventilation: state of the art. Mayo Clin Proc 2017;92:1382–400. 10.1016/j.mayocp.2017.05.004
    1. Jacob ST, Banura P, Baeten JM, et al. . The impact of early monitored management on survival in hospitalized adult Ugandan patients with severe sepsis: a prospective intervention study*. Crit Care Med 2012;40:2050–8. 10.1097/CCM.0b013e31824e65d7
    1. Machado FR, Ferreira EM, Schippers P, et al. . Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results. Crit Care 2017;21:268. 10.1186/s13054-017-1858-z
    1. Noritomi DT, Ranzani OT, Monteiro MB, 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 2014;40:182–91. 10.1007/s00134-013-3131-5
    1. Sazawal S, Black RE, Pneumonia Case Management Trials Group . Effect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta-analysis of community-based trials. Lancet Infect Dis 2003;3:547–56. 10.1016/s1473-3099(03)00737-0
    1. Maitland K, Kiguli S, Opoka RO, et al. . Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011;364:2483–95. 10.1056/NEJMoa1101549
    1. Andrews B, Semler MW, Muchemwa L, et al. . Effect of an early resuscitation protocol on in-hospital mortality among adults with sepsis and hypotension: a randomized clinical trial. JAMA 2017;318:1233–40. 10.1001/jama.2017.10913

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する