Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
www.asr.emilia-romagna.it area rischio Infettivo 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 (%)