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Sepsis in Brazilian emergency departments: a prospective multicenter observational study

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Abstract

We aimed to assess the prevalence, patient allocation adequacy, and mortality of adults with sepsis in Brazilian emergency departments (ED) in a point-prevalence 3-day investigation of patients with sepsis who presented to the ED and those who remained there due to inadequate allocation. Allocation was considered adequate if the patient was transferred to the intensive care unit (ICU), ward, or remained in the ED without ICU admission requests. Prevalence was estimated using the total ED visit number. Prognostic factors were assessed with logistic regression. Of 33,902 ED visits in 74 institutions, 183 were acute admissions (prevalence: 5.4 sepsis per 1000 visits [95% confidence interval (CI): 4.6–6.2)], and 148 were already in the ED; totaling 331 patients. Hospital mortality was 32% (103/322, 95% CI 23.0–51.0). Age (odds ratio (OR) 1.22 [95% CI 1.10–1.37]), Sequential Organ Failure Assessment (SOFA) score (OR 1.41 [95% CI 1.28–1.57]), healthcare-associated infections (OR 2.59 [95% CI 1.24–5.50]) and low-resource institution admission (OR 2.65 [95% CI 1.07–6.90]) were associated with higher mortality. Accredited institutions (OR 0.42 [95% CI 0.21–0.86]) had lower mortality rates. Allocation within 24 h was adequate in only 52.8% of patients (public hospitals: 42.4% (81/190) vs. private institutions: 67.4% (89/132, p < 0.001) with 39.2% (74/189) of public hospital patients remaining in the ED until discharge, of whom 55.4% (41/74) died. Sepsis exerts high burden and mortality in Brazilian EDs with frequent inadequate allocation. Modifiable factors, such as resources and quality of care, are associated with reduced mortality.

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Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We would like to thank the Tiago Mendonça dos Santos for statistical support. We want to express our gratitude to all participating emergency departments, as this relevant work for our country would not be possible without their commitment.

The SPREAD ED Investigators, the Instituto Latino Americano de Sepsis Network: SZSP Alves, CB Velasco - Complexo Hospitalar de Niterói; GF Sanches, LN Azevedo - Fundação Centro Médico de Campinas; EB Sobrinho, AOL Veríssimo - Hospital Adventista de Belém; AG Macedo - Hospital Adventista de Manaus; AP Borges, F Colombari - Hospital Alemão Oswaldo Cruz; A Habitante, GS Oliveira - Hospital Alvorada Moema; RM Filho, NM Gambero - Hospital Ana Costa; LC Machado - Hospital Brasília; JAL Albuquerque, SM Fernandes - Hospital Copa D’Or; BAMP Bessen, EVN Martins - Hospital da Luz Vila Mariana; MR da Silva, EF de Paula - Hospital de Clínicas da Unicamp; MMC Silva - Hospital de Clínicas de Uberlândia; AF Pereira, PA Quesado - Hospital De Clínicas Mário Lioni; G Fernandes - Hospital de Clínicas Nossa Senhora da Conceição /Associação Congregação de Santa Catarina; W Ayrão, N Kondratievans - Hospital de Doenças Tropicais Dr. Anuar Auad HDT/HAA; IR Leite, PKO Sá - Hospital de Emergência e Trauma Dom Luiz Gonzaga Fernandes; EA de Oliveira, IO de Freitas - Hospital de Pronto Socorro de Porto Alegre; D Pedroso, A Bonifácio - Hospital de Urgências de Goiânia; SA dos Santos Junior, MB do Amaral - Hospital Divina Providência; AAG Alves, SHCA Carvalho - Hospital Djalma Marques; JC Fernandes, CR Duarte - Hospital Ernesto Dorneles; GR Fonseca, LG Almeida - Hospital Estadual Jayme Santos Neves; LC de Oliveira Junior, RN de Oliveira - Hospital Geral Clériston Andrade; M Damos - Hospital Geral De Juiz De Fora; RNDM de Souza, VS dos Santos - Hospital Geral de Palmas Dr. Francisco Ayres; AR Durães, YSL Bitar - Hospital Geral Roberto Santos; F Liberali - Hospital Metropolitano De Várzea Grande; CA Branco - Hospital Miguel Arraes; LFS Varela - Hospital Moinhos De Vento; KAP Conde - Hospital Municipal Dr. José Soares Hungria; EA Peixoto - Hospital Municipal Santa Isabel; RB Pardo, L Delgatto - Hospital Municipal Vereador José Storopolli; CGC Jacob, A Silva - Hospital Next Santo Amaro; LMB Vinãs, KDA Coqueti - Hospital Next São Bernardo; MCG Ribeiro, GBA Faria - Hospital Oeste D'Or; DASF da Silva, JS Jardim - Hospital Pasteur; A Farias, AP Amorin - Hospital Português da Bahia; ZE Sakamoto, VHC Barros - Hospital Pronto Socorro João Lucio Pereira Machado; ALM Filho, DP de Oliveira - Hospital Quinta D’Or; R Guimarães, LF Pires - Hospital Regional de Presidente Prudente; MA Sicolo - Hospital Rio Grande; BBK Boettger, FA de Castro - Hospital Santa Catarina de Blumenau; JS Yamano, AR da Silva - Hospital Santa Cruz SP; CFD Dornelles - Hospital Santa Cruz; GP Alba, AP Correa - Hospital Santa Isabel; N de Alcantara - Hospital Santo Antônio; A Martins, NB Gouveia - Departamento de Pesquisa Imed, Hospital São Camilo Pompéia; RL Coelho, AT Maciel - Departamento de Pesquisa Imed, Hospital São Camilo Ipiranga; CSS Matos, EGL Guadalupe - Departamento de Pesquisa Imed, Hospital São Camilo Santana; M Pereira, R Rabe - Hospital São José/Associação Congregação Santa Catarina; T Smith, R Oliveira - Hospital São Lucas; C Toscan, MR e Karnikowski - Hospital São Lucas da PUC RS; FGR Freitas, AT Bafi - Hospital Sepaco; J Giacomazzi - Hospital Tacchini; PGMB e Silva, AN Rabaça - Hospital TotalCor; LES Fontes, AB Simões - Hospital Unimed Petrópolis; C Grion, J Festti - Hospital Universitário de Londrina; KR de Oliveira, S Xavier - Hospital Universitário de Petrolina; TS Giancursi, DF Maccari - Hospital Universitário do Oeste do Paraná; BGC Araujo, JF Ferreira - Hospital Vera Cruz; G Borges, A Dino - Hospital Vitória Curitiba; AH Soares, LF Vieira - Hospital Vitória Anália Franco; AM Soeiro, MT de Oliveira Junior - Instituto Do Coração - InCor/HCFMUSP; RS Lopes, F Moulin - O.S.S. Santa Marcelina Hospital Cidade Tiradentes; GC Fernandes, DA de Mattos - Santa Casa de Misericórdia de Juiz de Fora; FM Araujo, VOS Pereira - Santa Casa de Misericórdia de Passos; MV Arnoni, SP Santana - Santa Casa de São Paulo; E Zukeran, SRSA Velihovetchi - São Lucas Hospital das Clínicas; MAP Bronchtein, MT de Araújo - Seisa Serviços Integrados de Saúde Ltda - Hospital Next Guarulhos; R Borges, MT Ferreira - Unidade de Pronto Atendimento UAI Pampulha; R Borges, MT Ferreira - Unidade de Pronto Atendimento UAI São Jorge (UPA Sul); EY Hamada - Unidade de Pronto Atendimento de Varginha; G Marcatto - UPA Região Norte; C Piras, TR Pancini - Vitória Apart Hospital.

Funding

This work was supported by a research grant from Fundação de Apoio a Pesquisa do Estado de São Paulo, FAPESP, under the number 2017/21052-0 and an individual research grant (FRM) from Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq). The funding source has no influence in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Author information

Authors and Affiliations

  1. Instituto Latino Americano de Sepse, R Pedro de Toledo 980 Cj 94, São Paulo, SP, 04039-002, Brazil

    Flávia R. Machado, Alexandre B. Cavalcanti, Aline Bossa, Juliana L. Souza, Josiane F. Ferreira, Felipe dal Pizzol, Mariana B. Monteiro, Thiago Lisboa & Luciano C. P. Azevedo

  2. Anesthesiology, Pain and Intensive Care Department, Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, SP, Brazil

    Flávia R. Machado

  3. Brazilian Research in Intensive Care Network (BRICNet), São Paulo, SP, Brazil

    Flávia R. Machado, Alexandre B. Cavalcanti, Felipe dal Pizzol, Thiago Lisboa & Luciano C. P. Azevedo

  4. HCor Research Institute, São Paulo, SP, Brazil

    Alexandre B. Cavalcanti

  5. Associação Brasileira de Medicina de Emergência, São Paulo, Brazil

    Maria A. Braga

  6. Associação Brasileira de Medicina de Urgência, São Paulo, Brazil

    Fernando S. Tallo

  7. UPMC and the University of Pittsburgh Schools of the Health Sciences, Pittsburgh, PA, USA

    Derek C. Angus

  8. Disciplina de Emergências Clínicas, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil

    Luciano C. P. Azevedo

Authors
  1. Flávia R. Machado
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  2. Alexandre B. Cavalcanti
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  3. Maria A. Braga
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  4. Fernando S. Tallo
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  5. Aline Bossa
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  6. Juliana L. Souza
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  7. Josiane F. Ferreira
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  8. Felipe dal Pizzol
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  9. Mariana B. Monteiro
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  10. Derek C. Angus
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  11. Thiago Lisboa
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  12. Luciano C. P. Azevedo
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Consortia

The SPREAD ED Investigators, the Instituto Latino Americano de Sepsis Network

  • S. Z. S. P. Alves
  • , C. B. Velasco
  • , G. F. Sanches
  • , L. N. Azevedo
  • , E. B. Sobrinho
  • , A. O. L. Veríssimo
  • , A. G. Macedo
  • , A. P. Borges
  • , F. Colombari
  • , A. Habitante
  • , G. S. Oliveira
  • , R. M. Filho
  • , N. M. Gambero
  • , L. C. Machado
  • , J. A. L. Albuquerque
  • , S. F. M. Fernandes
  • , B. A. M. P. Bessen
  • , E. V. N. Martins
  • , M. R. da Silva
  • , E. F. de Paula
  • , M. M. C. Silva
  • , A. F. Pereira
  • , P. A. Quesado
  • , G. Fernandes
  • , W. Ayrão
  • , N. Kondratievans
  • , I. R. Leite
  • , P. K. O. Sá
  • , E. A. de Oliveira
  • , I. O. de Freitas
  • , D. Pedroso
  • , A. Bonifácio
  • , S. A. dos Santos Junior
  • , M. B. do Amaral
  • , A. A. G. Alves
  • , S. H. C. A. Carvalho
  • , J. C. Fernandes
  • , C. R. Duarte
  • , G. R. Fonseca
  • , L. G. Almeida
  • , L. C. de Oliveira Junior
  • , R. N. de Oliveira
  • , M. Damos
  • , R. N. D. M. de Souza
  • , V. S. dos Santos
  • , A. R. Durães
  • , Y. S. L. Bitar
  • , F. Liberali
  • , C. A. Branco
  • , L. F. S. Varela
  • , K. A. P. Conde
  • , E. A. Peixoto
  • , R. B. Pardo
  • , L. Delgatto
  • , C. G. C. Jacob
  • , A. Silva
  • , L. M. B. Vinãs
  • , K. D. A. Coqueti
  • , M. C. G. Ribeiro
  • , G. B. A. Faria
  • , D. A. S. F. da Silva
  • , J. S. Jardim
  • , A. Farias
  • , A. P. Amorin
  • , Z. E. Sakamoto
  • , V. H. C. Barros
  • , A. L. M. Filho
  • , D. P. de Oliveira
  • , R. Guimarães
  • , L. F. Pires
  • , M. A. Sicolo
  • , B. B. K. Boettger
  • , F. A. de Castro
  • , J. S. Yamano
  • , A. R. da Silva
  • , C. F. D. Dornelles
  • , G. P. Alba
  • , A. P. Correa
  • , N. de Alcantara
  • , A. Martins
  • , N. B. Gouveia
  • , R. L. Coelho
  • , A. T. Maciel
  • , C. S. S. Matos
  • , E. G. L. Guadalupe
  • , M. Pereira
  • , R. Rabe
  • , T. Smith
  • , R. Oliveira
  • , C. Toscan
  • , M. R. e Karnikowski
  • , F. G. R. Freitas
  • , A. T. Bafi
  • , J. Giacomazzi
  • , P. G. M. B. e Silva
  • , A. N. Rabaça
  • , L. E. S. Fontes
  • , A. B. Simões
  • , C. Grion
  • , J. Festti
  • , K. R. de Oliveira
  • , S. Xavier
  • , T. S. Giancursi
  • , D. F. Maccari
  • , B. G. C. Araujo
  • , J. F. Ferreira
  • , G. Borges
  • , A. Dino
  • , A. H. Soares
  • , L. F. Vieira
  • , A. M. Soeiro
  • , M. T. de Oliveira Junior
  • , R. S. Lopes
  • , F. Moulin
  • , G. C. Fernandes
  • , D. A. de Mattos
  • , F. M. Araujo
  • , V. O. S. Pereira
  • , M. V. Arnoni
  • , S. P. Santana
  • , E. Zukeran
  • , S. R. S. A. Velihovetchi
  • , M. A. P. Bronchtein
  • , M. T. de Araújo
  • , R. Borges
  • , M. T. Ferreira
  • , R. Borges
  • , M. T. Ferreira
  • , E. Y. Hamada
  • , G. Marcatto
  • , C. Piras
  •  & T. R. Pancini

Contributions

FRM: had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. FRM: assumes full responsibility for the integrity of the submission as a whole, from inception to the published article. FRM, ABC, AB, FDP, FST, JL, MAB, MBM, TL, LCPA: contributed substantially to the study design. FRM, ABC, AB, FDP, FST, JL, MAB, MBM, TL, LCPA: contributed substantially to data collection. FRM, ABC, AB, FDP, FST, JL, MAB, MBM, TL, LCPA: contributed substantially to the data analysis and interpretation, and the writing of the manuscript. All authors read and approved this manuscript before submission.

Corresponding author

Correspondence to Flávia R. Machado.

Ethics declarations

Conflict of interests

We declare that we have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Research Ethics Committee (ERB) at the coordinating center (Federal University of São Paulo) under the number CAAE: 60953816.4.1001.5505.

Consent to participate

Informed consent was waived because of its observational nature and no direct involvement of patients beyond data collection from patients’ charter.

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The SPREAD ED Investigators, the Instituto Latino Americano de Sepsis Network members name listed in acknowledgement section.

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Machado, F.R., Cavalcanti, A.B., Braga, M.A. et al. Sepsis in Brazilian emergency departments: a prospective multicenter observational study. Intern Emerg Med 18, 409–421 (2023). https://doi.org/10.1007/s11739-022-03179-3

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