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Background: Continuous investment and systematic evaluation of program accomplishments are required to achieve excellence in ST-segment elevation myocardial infarction (STEMI) care, especially in resource-limited settings. Therefore, this study evaluates the impact of problem-driven interventions on reperfusion use rate in a long-term operating STEMI network from a low- to middle-income country. Methods: This is a healthcare improvement evaluation study of Salvador's public STEMI network in a quasi-experimental design, comparing data from 2009 to 2010 (pre-intervention) and 2019-2020 (post-intervention). There were evaluated all confirmed STEMI cases assisted in both periods. The interventions, implemented since 2017, included: expanding the support team, defining criteria to be a spoke, and initiating continuous education activities. The primary outcome was the rate of patients undergoing reperfusion, with secondary outcomes being time from door-to-ECG (D2E) and ECG-to-STEMI-team trigger (E2T). Results: Over ten years, the network's coverage increased by 300,000 individuals, and expanded by 1,800 km2. A total of 885 records were analyzed, 287 in the pre-intervention group (182 men [63·4%]; mean [SD] age 62·1 [12·5] years) and 598 in the post-intervention group (356 men [59·5%]; mean [SD] age 61.9 [11·8] years). It was noticed a substantial increase in reperfusion delivery rate (90 [31%] vs. 431 [73%]; P = 001) and reductions in time from D2E (159 [83-340] vs. 29 [15-63], P = 001), and E2T (31 [21-44] vs. 16 [6-40], P = 001). Conclusion: The strategies adopted by Salvador's STEMI network were associated with significant improvements in the rate of patients undergoing reperfusion and in D2E and E2T. However, the mortality rate remains high.
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OBJECTIVE: ICU severity scores such as the Sequential Organ Failure Assessment (SOFA) determine neurologic dysfunction based on the Glasgow Coma Scale, a tool that may be limited in a critically ill population. It remains unknown whether alternative methods to assess for neurologic dysfunction, such as FOUR and RASS, are superior. This study aimed to determine the predictive performance of a modified SOFA tool in a large Brazilian ICU cohort. DESIGN: Prospective cohort single center study. SETTING: Mixed surgical and medical ICU in Salvador, Bahia, Brazil between August 2015 and December 2018. PATIENTS: All acutely ill ICU admissions, other than postoperative patients or those with insufficient data, were eligible for study inclusion. MEASUREMENTS AND MAIN RESULTS: 2147 patients were admitted to the ICU, of which 999 meeting inclusion criteria were included in the final analysis with a median age of 72 years (IQR 58-83) and a female predominance 545 (54%). The SOFA score using GCS, RASS and FOUR for the neurologic component performed marginally in the ability to predict general ICU mortality (SOFAGCS AUC 0.74 vs SOFARASS AUC 0.71 and SOFAFOUR AUC 0.67), with SOFAFOUR performing significantly lower compared to either SOFARASS and SOFAGCS (p<0.04, p<0.004 respectively). All three scores demonstrated decreased discriminate function in the mechanically ventilated population (SOFAGCS AUC 0.70 vs SOFARASS AUC 0.70 and SOFAFOUR AUC 0.55), though SOFAFOUR remained significantly worse when compared to SOFAGCS or SOFARASS (p = 0.034, p = 0.014, respectively).. Furthermore, performance was poor in a subset of patients with sepsis (n = 145) at time of admission (SOFAGCS AUC 0.66 vs SOFARASS AUC 0.55 and SOFAFOUR AUC 0.56). CONCLUSION: Modification of the neurologic component in the SOFA score does not appear to improve mortality prediction in the ICU.