Journal Club: la gestione in pillole SOPRAVVIVERE ALLA SEPSI: I PRIMI 5 ANNI Dalla linea guida al...
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Transcript of Journal Club: la gestione in pillole SOPRAVVIVERE ALLA SEPSI: I PRIMI 5 ANNI Dalla linea guida al...
Journal Club: la gestione in pillole
SOPRAVVIVERE ALLA SEPSI: I PRIMI 5 ANNI
Dalla linea guida al paziente: cosa abbiamo fatto per il paziente settico
Dott. Marco Marietta Dott.ssa Lara Donno
Video meliora proboque sed deteriora sequorOvidio, Metamorfosi
PROBLEM EXTENT
Italian ICU registry (margherita project, GIVITI Italian ICU registry (margherita project, GIVITI
group): group):
SEPTIC SHOCK patientsSEPTIC SHOCK patients
2006: 158 ICUs, n 2160, H MORTALITY 2006: 158 ICUs, n 2160, H MORTALITY
62,1%62,1%
2007: 157 ICUs, n 2347, H MORTALITY 2007: 157 ICUs, n 2347, H MORTALITY
61,2 %61,2 %
2008: 174 ICUs, n 3067, H MORTALITY 2008: 174 ICUs, n 3067, H MORTALITY
60,9%60,9%
2009: 180 ICUs, n 3229, H MORTALITY 2009: 180 ICUs, n 3229, H MORTALITY
59,0%59,0%
SEVERE SEPSIS AND SEPTIC SHOCK MORTALITY IS STILL TOO HIGH….. !!!
MISSION1) Increase awareness, understanding and knowledge 2) Define standards of care in severe sepsis 3) Reduce the mortality associated with sepsis by 25% over the next 5 years
severe sepsis/ septic shock
MORTALITY IS STILL TOO HIGH
knowledge of disease
mechanisms
Guidelines
Methods
Materials
Host response
Therapies: mode of action
Effectiveness in vivo
Bundles over- simplificationOther therapies
PROBLEM ANALYSIS
Microorganism effects
Applicability
Patient Identification
No process issues
Education
Specific processes
Microorganism identification
Therapies available
QUALI STRUMENTI
QUALI STRUMENTI ?
Bundles Pre
Resuscitation (%paz) 5,3
Management (%paz) 10,9
SSC PHASE IIIGuidelines application
Bundles Pre
Resuscitation (%paz) 0,0
1 ED
59 ICUs
WHY BUNDLES ?
JAMA. 1999;282:1458-JAMA. 1999;282:1458-1465. 1465.
if 80% transfer at every stage… just 21% of pts. usage
Eight “A” of the Eight “A” of the evidence pipelineevidence pipeline1. Awareness2. Acceptance3. Applicable4. Available 5. Able6. Acted on7. Agreed to8. Adhered to
Median absolute improvement in performance:14.1% in 14 cluster randomised comparisons of reminders 8.1% in four cluster randomised comparisons of dissemination of educational materials, 7.0% in five cluster randomised comparisons of audit and feedback6.0% in 13 cluster randomised comparisons of multifaceted interventions involving educational outreach. No relationship was found between the number of component interventions and the effects of multifaceted interventions.
ARR = 4,3% ARR = 4,3% NNT = 23NNT = 23
59 SPAIN ICUs, 2 months educational program59 SPAIN ICUs, 2 months educational programSevere sepsis and septic shock patients: Severe sepsis and septic shock patients:
n= 859 PRE education (Nov-Dec 2005) n= 859 PRE education (Nov-Dec 2005) (APACHE II 21)(APACHE II 21)
n =1465 POST education (Mar-Jun 2006) n =1465 POST education (Mar-Jun 2006) (APACHE II 21)(APACHE II 21)
Bundle Pre Post
Resuscitation (%pat) 5,3 10,0
Management (%pat) 10,9 15,7
WHY BUNDLES ? WHY BUNDLES ?
Bundles Pre Post 2 months
Past 1 year
Resuscitation (%paz) 6,3 12,9 7,3
Management (%paz) 9,4 19,6 26,7
H mortality (%paz) 42,5 38,7 38,5
2 months education
programLong term analysis:
23/59 ICUs
Key Points: EDUCATION
Bundles Pre Post
Resuscitation (%paz) 0,0% 51%
1 ED
Key Points: EDUCATION + PROCESSES
Education+
Process changes
At long-term follow-up, some of the improvements achieved by the educational program had returned to baseline, especially process-of-care measures in the acute phase of treatment.However, it is well-known that quality improvement initiatives should be sustained, especially in areas like the emergency department in which physician turnover is higher than in other areas of the hospital. Applying the “plan-do-study-act” cycles is probably the best approach to sustain the effect of the educational program.
Key Points: NOT ONLY EDUCATION
SSC PHASE IIIKey Points: SPECIFIC PROCESSES
1. Establish a multidisciplinary working group 2. Analyze actual sepsis management/outcome3. 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 to support clinical decision
4. Measurement - education- process-changes- guidelines application- patients outcomes- economy