Banca de QUALIFICAÇÃO: CLAUDIA REGINA FERNANDES

Uma banca de QUALIFICAÇÃO de MESTRADO foi cadastrada pelo programa.
STUDENT : CLAUDIA REGINA FERNANDES
DATE: 04/08/2026
TIME: 09:00
LOCAL: Departamento de Nutrição - UFRN (formato remoto)
TITLE:

IMPROVEMENT CYCLE IN THE IMPLEMENTATION OF THE SEPSIS PROTOCOL IN A TERTIARY TEACHING HOSPITAL

KEY WORDS:

Sepsis; Clinical protocols; Patient safety; Quality Indicators, Health Care; Teaching Hospitals.

PAGES: 43
BIG AREA: Ciências da Saúde
AREA: Medicina
SUMMARY:

Background: Sepsis is one of the leading causes of in-hospital mortality, demanding effective organizational strategies for its early recognition and management. Evidence-based clinical protocols have been widely recommended as tools to improve the quality of care. At the Walter Cantídio University Hospital (HUWC), a high sepsis mortality rate was observed, which was associated with the absence of a structured managed protocol, failures in the standardization of care processes, and low adherence to recommended practices. Objective: To evaluate the results of the improvement cycle in the implementation and management of the Sepsis Protocol at HUWC/UFC over a one-year period. The analysis focuses on three main axes: quality of care indicators, multidisciplinary team adherence, and operational challenges faced during execution. Method: A quasi-experimental, before-and-after study without a control group, utilizing a mixed-methods (quantitative and qualitative) approach, conducted through a quality improvement cycle. Process and outcome indicators were analyzed in adult patients with suspected or diagnosed sepsis, using data collected through medical record reviews and standardized care charts. Intervention: The intervention included the implementation of the institutional Sepsis Protocol, with the definition of quality criteria, training of the multidisciplinary team, implementation of the MEWS (Modified Early Warning Score) system, standardization of data collection, and continuous monitoring of healthcare indicators. Results: A total of 719 admissions were analyzed, with 161 suspected cases of sepsis, of which 87 progressed to protocol activation. A mean time of 41.5 minutes was observed for antibiotic administration, meeting the institutional target in most months. There was a reduction in mortality over the period, although with temporal variability. Weaknesses in laboratory sample collection persisted, with low compliance and variability in care processes. No statistically significant association was identified between the time to antibiotic therapy and the mortality outcome ($p = 0.75$). Conclusions: The use of the improvement cycle for the implementation of the sepsis protocol contributed to advances in the quality of care and a reduction in mortality, although results remain heterogeneous. The sustainability of the intervention depends on continuous monitoring, continuing education, and the strengthening of organizational processes.

COMMITTEE MEMBERS:
Presidente - 4659679 - SANCHA HELENA DE LIMA VALE
Interna - 1645299 - MARISE REIS DE FREITAS
Interna - 2330137 - VILANI MEDEIROS DE ARAUJO NUNES
Externa à Instituição - CLAUDIA FERNANDA DE LACERDA VIDAL - UFPE