1. Epimed to assist critical care research
Jorge Salluh
Intensive care dept, Instituto D’Or de Pesquisa e Ensino
Founder Epimed Solutions
Researcher FAPERJ and CNPq
BRICNet – Brazilian Research in Intensive Care Network
Paris, 2017

2. Founder and shareholder at Epimed Solutions
Conflicts of Interest
Founder and shareholder at Epimed Solutions

3. Critical Care in Brazil
A quick overview
Critical Care in Brazil
Salluh & Lisboa, ICU management, 2016

4. Critical Care in Brazil
A quick overview
Critical Care in Brazil
Salluh & Lisboa, ICU management, 2016

5. Distribution of ICU beds
Brasil - public
Brasil - private
Salluh & Lisboa, ICU management, 2016

6. Some Landmarks for critical care in Brazil
1998 – Ministry of Health regulations determine that all adult ICUs must calculate Standardized Mortality Ratios
Brazilian Critical Care Society (AMIB) establish its updated (second) set of quality of care standard metrics.
2010 – Governmental regulatory agency (ANVISA) establishes 11 quality of care indicators that must be recorded by every adult ICU in the country
2015 – Epimed and AMIB establishes the National ICU registry based on Epimed ICU module data

7. Challenges Develop and implement a QI program
Ability to collect data in a large scale
Heterogeneous adoption of EMRs
Need to make not only data collection, but QI feasible in real world scenario

8. What is Epimed Monitor ? Cloud-based quality improvement ICU analytics
Brazilian company founded in 2008 by ICU physicians
Focus on QI, Epidemiology, advanced analytics and research

9. Answers to the Challenge
Multiplatform easy to use interface
Full Cloud Solution (Safe, Privacy secured, Encrypted, Anonimyzed)
Real-time reports and Interactive Dashboards
Clear Definition of Core data, additional QI data, Checklists and Bundle plugins to be adopted as stand-alone or to allow a stepwise implementation
Fully exportable dataset and reports in
friendly format
Monthly Local meetings + National
annual meeting for feedback and training

10. Premises Light and easy to use Mobile compatible
Able to interface with EMRs
Real-Time availability of information as a driver of CHANGE (data on Process/Outcomes)
Accessible and up to date (near-real-time/ real-time) Benchmarking

11. Landmarks of our Project
2008
5 ICUS
2 Cities
2009
49 Hospitals
69 ICUs
759 Beds
2011
134 Hospitals 203 ICUs 2728 Beds
End of 2014
600 ICUs 8200 Beds
1 Million patients
2015
Brazilian Registry
Beginning of activities in Colombia
Partership with AMCI (Colombia Crit Care Society)
Activities in Uruguay

12. Epimed in numbers (2017) EPIMED MONITOR 5 Countries 180 Cities
400 HOSPITALS
800 ICUs
ICU beds
ICU admissions

13. What makes Epimed a hub for research ?
11,000 users (ICU physicians and Nurses)
Structured core data on clinical characteristics, outcomes and process of care
Real-time reports
+ 30,000 adult ICU admissions/month

14. A robust database for cohort studies;
Validated in single and multicenter international studies in intensive care;
Potential to identify patients for clinical trial entry
More than 20 publications (abstracts and full-papers) per year use and cite Epimed Monitor;
Some studies in major Journals that used Epimed as database:
Crit Care. 2010;14(6):R210. doi: /cc9333
Crit Care Apr 4;17(2):R63. doi: /cc12594
Crit Care Jul 21;18(4):R156. doi: /cc13995.
Ann Oncol Sep;25(9): doi: /annonc/mdu234
Crit Care. 2014,18:580 doi: /s
Intensive Care Med Dec;41(12):
JAMA Apr 12;315(14):
J Clin Oncol Sep 20;34(27):
Intensive Care Med Jan;43(1):39-47

15. Knowledge on Epidemiology to design RCTs and Govt Projects
Sample Size Calculation for Observational Studies and RCTs recently published in Top Journals (ex-JAMA Apr 12;315(14): )
Background information to design and apply for Grant propositions (ie- Recent wellcome trust and Gates foundation applications; BASICS trial)
Information on Sepsis Mortality for the Brazilian MOH sepsis project

16. Epidemiology and Cohort studies

17. Delirium epidemiology in critical care (DECCA): an international study
Delirium is frequent (32-65%) and doubles the risk of death. Preventable causes were identified and led to QI projects
Crit Care. 2010;14(6):R210.

18. Early Sedation and Outcomes in Mechanically Ventilated Patients (Crit Care. 2014 Jul 21;18(4):R156)
Early oversedation is associated with worst outcomes and is a target for QI initiatives

19. Quality Improvement studies

20. Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost- effectiveness in a long-term follow-up study
Noritomi et al, Intensive Care Med (2014) 40:182–191
12 Hospitals in Sao Paulo implemented electronic-driven bundles and sepsis case management for 18 months – a before-and-after study

21. Ranzani et al. Critical Care 2014, 18:580
Evaluation of a minimal sedation protocol using ICU sedative consumption as a monitoring tool: a quality improvement multicenter project
10 Hospitals in Sao Paulo implemented electronic-driven and pharmacist management of sedative consumption for 2– a before-and-after study resulted in decreased sedative consumption and MV days

22. Optimizing the connection between researchers…
The ORCHESTRA (ORganizational CHaractEriSTics in cRitical cAre) Study

23. THE ORCHESTRA studies
78 Brazilian intensive care units: the ORCHESTRA study.
Data from 2013
60,000 ICU patients
Surveys on Structure and Process of Care

24. THE ORCHESTRA studies
Organizational characteristics, outcomes, and resource use in 78 Brazilian intensive care units: the ORCHESTRA study.
(Intensive Care Med Dec;41(12): )
Effects of Organizational Characteristics on Outcomes and Resource Use in Patients With Cancer Admitted to Intensive Care Units. (J Clin Oncol Sep 20;34(27): )
The effects of performance status one week before hospital admission on the outcomes of critically ill patients. (Intensive Care Med Jan;43(1):39-47)
Family care, visiting policies, ICU performance, and efficiency in resource use: insights from the ORCHESTRA study. (Intensive Care Med , in press)
5 additional papers being drafted

25. THE ORCHESTRA 2...so far
92 Brazilian intensive care units
ICU beds
Data from 2014 and 2015
130,000 ICU patients

26. International Collaboration
Current research collaborations with…
ICNARC –UK – Improving Sepsis Reporting Characteristics and Outcomes Project
MIMIC-II USA/ANZICS-CORE – Global open source Scoring system development study

27. Conclusions
Epimed is currently one of the largest systems for quality improvement and ICU performance management and opens interesting possibilities for ICU research in a large and well-structured database
There is a great potential for studies on both highly frequent/relevant ICU topics as well as rare diseases