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SEPSIS REGIONAL PROGRAM
LaSER
Audit and Outcomes
The “aim”
o The LASER project has been developed by Agenzia
Sanitaria Regionale in the context of PRI-ER program
(Research and Innovation program- Emilia Romagna).
o The main objective of LASER project is to
promote the transfer in clinical practice
of all interventions that can reduce
mortality of septic patients
The Methods
1) Spreading evidence-based interventions in
the regional Hospitals :
educational programs
2) Systematic Updating of innovations in sepsis
multidisciplinary groups on sepsis issues
3) Evaluation of the LASER impact
clinical database for ICU patients
clinical Audit in no-ICU patients
4) Evaluation of efficacy/safety profile for
specific interventions in the clinical context.
How the regional program:
the “REGIONAL NETWORK BUILDING”
HOSPITAL ‘SEPSIS TEAM’ (minimal composition):
(1)ICU doctor specialist in sepsis
(2)ICU Nurse
(3)Emergency Department doctor
(4)Hospital Organization doctor
(5)Infectious disease specialist
(6)Nurse dedicated to infection surveillance program in Hospital,
How the regional program:
“DOCUMENTS”
Regional program:
which interventions ?
the regional program:
Which interventions…
(Re)-evaluation of
clinical interventions:
REGIONAL GROUP
RACCOMANDATIONS
BY ‘GRADE’ METHOD
rhAPC
Completed
Steroids
Voting
Glycaemia
Voting
Antibiotics
Analysis
Immunoglobulins
Analysis
Extracorp. therapy
Analysis
How the regional program:
“EDUCATION”
Step # 1 2006-2007
HOSPITAL TEAMS
• 3 days residential course in different sites of ER
• Contents: from sepsis incidence to organization of the
Hospital for sepsis management.
• Frontal presentation, group working, role-play case
discussion.
• 5 editions from OCT 06 to SEP 07
• 4-5 Hospital Teams for each edition. T
• TRAINED: 25 TEAMS (sep 07): 50 ICU-doctors, 23 EDDoctors, 18 Infectious disease specialist, 47 Hospital
Direction doctor, 46 Nurses.
How the regional program:
“EDUCATION”
Step # 2 2008
SINGLE HOSPITAL
Nurses
Doctors
M
edici Infermieri
AUSL Piacenza
AUSL Parma
AO Parma
AO Reggio
AUSL Reggio
AUSL M odena
AO M odena
Hesperia Hospital
AO Bologna
AUSL Bologna
AUSL Imola
AO Ferrara
AUSL Ferrara
AUSL Ravenna
AUSL Forlì
AUSL Cesena
AUSL Rimini
Totale*
Totals
Totale
144
20
182
49
58
59
196
10
38
153
132
89
47
*
NR
48
62
604
102
434
201
150
268
406
30
255
499
482
325
171
*
NR
204
112
748
122
616
250
208
327
602
40
293
652
614
414
218
270
0
252
174
1287
4243
5800
LASER impact: Organization
Accessibilità al
laboratorio
microbiologico
Possibilità di eseguire
emocolture in Pronto
soccorso (PS)
In 10 Aziende è possibile accettare i campioni da
sottoporre a indagine microbiologica 7 giorni su 7.
Alcune di queste Aziende hanno allargato l’accessibilità
durante il progetto.
13 Aziende è possibile eseguire le emocolture in PS e
che nella maggior parte dei casi tale opportunità è
stata realizzata nell’ambito del progetto.
La determinazione del lattato in urgenza è possibile in
16 Aziende; la disponibilità di accettazione di richieste
Possibilità di ottenere il in contesti non intensivi è stata introdotta durante il
progetto. Un profilo ematochimico “sepsi” in urgenza è
lattato in urgenza
stato attivato in 8 Aziende e in alcune di queste è stato
introdotto dopo LaSER.
Possibilità di eseguire
l’Early Goal Directed
Therapy (EGDT)
Attivazione di percorsi
diagnostico/terapeutici
specifici
Lo strumento della consulenza per i pazienti con sepsi
(erogata principalmente da rianimatori/intensivisti o
team multidisciplinari) ricoverati nei vari reparti è
stata attivata in 13 Aziende, 7 giorni su 12 Aziende.
Sono presenti in 7 Aziende.
Impatto LASER:
Identificazione del paziente
Stima della incidenza di sepsi grave nella
Regione Emilia-Romagna, 1998-2010: banca dati
SDO
200,0
Tasso per 100.000 abitanti
180,0
Laser
160,0
140,0
120,0
100,0
80,0
60,0
40,0
20,0
0,0
1998
1999
2000
2001
2002
1998-2005
2003
2004
2006-2008
2005
2006
2007
Lineare (1998-2005)
2008
2009
2010
Impatto LASER:
modifiche nei processi
 Aumento progressivo delle emocolture eseguite: da
35/100 ricoveri del 2005 a 45/100 ricoveri 2008
 Aumento progressivo delle emocolture positive .
120
100
80
60
Tasso di batteriemia per
100.000
abitanti,
escluse le forme da
stafilococchi coagulasi
negativi, corinebatteri e
da
altri
possibili
contaminanti
cutanei,
Regione
EmiliaRomagna 2005-2008.
40
20
0
2005
2006
2007
2008
ESCHERICHIA COLI
PSEUDOMONAS AERUGINOSA
KLEBSIELLA PNEUMONIAE
ENTEROCOCCUS FAECALIS
ENTEROCOCCUS FAECIUM
SERRATIA MARCESCENS
STREPTOCOCCUS PNEUMONIAE
STAPHYLOCOCCUS AUREUS
LASER impact in ICU
Clinical Audit in ICU
- Pre-Post Intervention
- 10 ICUs;1000 patients
Work in
progre
ss
LASER impact in ICU
Clinical Audit in ICU: the DATABASE
LASER impact in ICU
Clinical Audit in ICU: comparison with others
LASER impact in ICU
Clinical Audit in ICU: 6 hours interventions
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2007
2008
General Hospital mortality & Education
Sepsis-Targeted (GHEST- Project)
- 6 Hospitals from 2004 to 2008
- departments responsible 80% of H deaths (not only sepsis!)
- 357.270 patients with H length of stay > 24 H
- H Mortality estimated by multivariate model W/WO education
7
Estimated
mortality without
education
M o r ta lità
(% )
6
5
Observed Mortality
4
3
Mortality reduction:
2
Sepsis education
1
2007
2008
0
1
4
7
10
13
16
19
22
25
28
31
Mesi
34
37
40
43
46
49
52
55
58
•2007: 25 deaths/month
•2008: 32 deaths/month
•2 yrs: 692 deaths
LASER impact in ICU:
computer decision support system
PATIENT DATA
SUGGESTED
THERAPY
GUIDELINES &
INSTRUCTIONS
LASER impact in ICU:
computer decision support system
ICU, Modena University Hospital
36 patients with septic shock randomized in Manager
and Normal group
80%
70%
*
% patients
60%
**
50%
40%
Normal
Manager
30%
20%
10%
0%
Bundle 6 ore
Bundle 24 ore
Bundles
*= p 0.005
**=p 0.015
STEP # 1:
CREATE A NETWORK
IN-HOSPITAL WORKING GROUP
PROJECT GROUP
2 ICU
1 H Administration
1 Infectiuos disease
1 Internal Medicine
HOSPITAL
ADMINISTRATION
In-Hospital
Program
9 Physicians from dep. with  sepsis
3 Nurses from dep. with  sepsis
1 Microbiologist
1 Laboratory Physician
1 Pharmacist
1 Specialist in Quality Assurance
1 Head Nurse infection surveillance pr.
IN-HOSPITAL
INFECTION
JOINT-COMITEE
AIMS
PRIMARY :
i) Improve clinical outcome of septic patients in the hospital
SECONDARY:
i) Optimize clinical management of septic patient.
ii) Reduce ICU and hospital stay of septic patient.
iii) Develop research projects on sepsis.
EDUCATION
INFORMATION
- Hospital Managers
- Nurses, Doctors
- Patients
CLINICAL and
ORGANIZATIONAL
PROTOCOLS
- pre- ICU
- ICU
PERORMANCE
MEASUREMENT
- Sepsis incidence
- Sepsis management
STEP # 2:
EDUCATION
Subjects & Methods
- In-Hospital health-care personnel (from lab to coroner)
- In-Hospital administrators
- Continuous education (turn-over + refresh)
- All education modalities (from standard lectures to simulation)
- Continuous feed-back (audit processes)
EDUCATION 2004-2008*
COURSES: BASIC + ADVANCED + REFRESH
Partecipants
DOCTORS
350 (out 500)
NURSES
450 (out 950)
From 2007: obligatory education program for all departments
STEP # 3:
PROCESS CHANGES
1. Establish a multidisciplinary working group
2. Analyze actual sepsis management/outcome
3. Institute specific processes for sepsis management
- create easy instruments for patient identification
- define level of care and criteria for Hospital and ICU admissions
- create tailored protocols for different departments (ED, Surgery, ICU)
- create a specific team (SEPSIS TEAM) to support clinical decision
4. Measurement
- education, process-changes, guidelines application, outcomes
TEAM SEPSI
GENNAIO 2008 – DICEMBRE 2011
TOTALE PAZIENTI 665
PAZIENTI MESE: 13,7 ± 4,9
CHIAMATE PER PAZIENTE: 1, 3 ± 0,9
ATTIVAZIONE CORRETTA : 80%
RICOVERI ICU: 222 (33%)
ICU (2005-2009) severe sepsis/septic
shock
BUNDLES COMPLIANCE
Percentage of patients
n =195
24 H bundle
Percentage of patients
6H bundle
(2005-2008)
severe
sepsis/septic
TIICU
(2005-2008)
severe
sepsis/septic
shock
shock
BUNDLESMORTALITY
COMPLIANCE
Septic shock n = 85
SEPSIS TEAM
90
EDUCATION
80
70
60
SAPS II
50
hospital
40
30 days
30
20
10
-
SAP
S II
Jan
05
gen04-
July
05
lug05-
Jan
06
gen06-
July
06
lug06-
Jan
07
gen07-
July
07
lug07-
Jan
08
gen08-
July
08
lug08-
giu05
Jun
05
dic05
Dec
05
giu06
Jun
06
dic06
Dec
06
giu07
Jun
07
dic07
Dec
07
Jungiu08
08
dic08
Dec
08
50±16
58±27
64±24
56±16
61±16
65±19
54±17
56±21
GIViTI
Septic Shock
year
SAPS II
Mort.H
2005
55±18
62,2
2006
55±18
61,1
ICU (2005-2008) septic shock
NO CIRRHOTIC PATIENTS
Mortality & Sepsis Bundles
Girardis et al. Cri Care 2009
ICU (2005-2008) septic shock
CIRRHOTIC PATIENTS
Mortality & Sepsis Bundles
BUNDLES
BUNDLES
COMPLETED
NOT
6h bundle
COMPLETED
15
23
50 ± 12
52 ± 10
27
30
12 (80)
16 (70)
1(7)
5 (22)
2 (13)
2 (9)
39 ± 11
33 ± 12
11 (73)
14 (61)
6 (43)
9 (39)
Blood (n, (%))
7 (47)
14 (61)
Urinary tract (n, (%))
7 (47)
9 (39)
68 ± 16
67 ± 22
17 ± 2
16 ± 3
13 (86,6)
18 (78,2)
Patients (n)
Age (years; mean ± SD)
Female (%)
Cirrhosis aetiology
Viral (n,(%))
Alcoholic (n, (%))
Other (n, (%))
MELD score (mean ± SD)
Site of infection
Pneumonia (n, (%))
abdominal infection (n,
(%))
SAPS II (mean ± SD)
SOFA (mean ± SD)
30 day mortality (n, (%))
24 h bundle
Rinaldi et al. J Crit Care 2012
TakeHomePicture
LASER impact in ICU
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
2007
2008
Sopravvissuti TI (%)
Sopravvissuti H (%)