The document evaluates indicators of a sepsis protocol at a municipal hospital in São Bernardo do Campo, Brazil in 2014. It found that 94% of patients had blood cultures collected, 88% received gas analysis within 30 minutes, and 76% received antibiotics within the first hour as required by the protocol. The most common diagnoses where urinary tract infections in 46% of cases and pneumonia in 10% of cases. Outcomes were 96% discharged, 3% transferred, and 1% death. The conclusions call for improving documentation of protocol use and ensuring antibiotic administration within an hour to better treat sepsis cases.

1. Evaluation of Sepsis Protocol Indicators of the Municipal Hospital University
of São Bernardo do Campo
Jaqueline Tonelotto, Carla R. Y. Kobayashi, Selma M. Costa, João G. Negrão, Mônica Carneiro, Cristiane Leimi
Municipal Hospital University of São Bernardo do Campo – São Paulo, Brazil
ABSTRACT
About 10 – 15% of the brazilian Intensive Care Units beds are occuped by patients with sepsis
with a mortality rate up 60%. Early diagnosis and the introduction of a set of systematic and multi-way
pipes can reduce this mortality.
In mid 2011 began the creation of the institucional protocol of sepsis, in 2012 training and
implementation, in 2013 we joined the fighting SEPSIS Program the Ministery of Health of Brazil.
Our objective was analyzed protocol indicators sepsis 2014 and analyzed the team in the care
of this patient.
METHODS
From 2014 the Patient Safety Team was responsible for managing the sepsis
protocol notification forms, fill the sheet indicators and perform the review with the aim of
increasing patient safety in our hospital.
RESULTS
In 2014, 136 cases were reported and analyzed indicators of the first hour of
applying protocol. Blood culture in 94% of patients, 5% not collected and 1% without
information, gas analysis within 30 minutes of opening the protocol in 88% of cases, not held
on 7% and no information in 1% .Antibiotics in the first hour of the Protocol: 76%, 24% did
not receive in the first hour. Cases: 81% were performed in obstetrics, 13% in gynecology
and 6 % without information. The main diagnosis was urinary tract infection in 46% of cases,
pneumonia in 10% and wound infection in 6% .These cases were classified as sepsis in 95%,
2 % severe sepsis and 3% septic shock. The outcome of patients: 96% discharge, 3% hospital
transfer and 1% death
3 3
8 9
1 2 1
3
1 2 3
1 0
4
1 1
6
18
9
15 14 13
21
14
18
2
NUMBER OF CASES OF SEPSIS DURING THE YEARS 2013/2014
2013 2014

2. Evaluation of Sepsis Protocol Indicators of the Municipal Hospital
University of São Bernardo do Campo
Jaqueline Tonelotto, Carla R.I. Kobayashi, Selma M. Costa, João G. Negrão, Mônica Carneiro, Cristiane Leimi
Municipal Hospital University of São Bernardo do Campo – São Paulo, Brazil
RESULTS CONTINUED CONCLUSIONS
REFERENCES
We conclude that there´s a deficit filling of the sepsis protocol notification forms, which the
team needs to prescribe and administer the antibiotic in the first hour of the Protocol and
how to proceed prior collection held blood tests Actions: meetings with the teams exposing
indicators and items to improve playful, training how to proceed in cases giving rise to
suspicion of sepsis and distribution of buttons with the information of clinical suspicion of
sepsis.
• Sepsis Program of the Ministry of Health of Brazil
YES
94%
NO
5%
NO INF
1%
BLOOD CULTURE COLLECTED, 2014
YES
88%
NO
7%
NO INF
5%
GAS ANALYSIS WITHIN 30
MINUTES, 2014
YES
76%
NO
24%
ANTIBIOTIC IN THE
FIRST HOUR, 2014
DISCHAR
GE
96%
TRANSF
3%
DEATH
1%
OUTCOME OF THE PATIENTS, 2014
SEPSIS
95%
SEVERE
SEPSIS
2%
SEPTIC
SHOCK
3%
CLASSIFICATION OF SEPSIS, 2014