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Transcript of Www.asr.emilia-romagna.it area rischio Infettivo SEPSIS REGIONAL PROGRAM LaSER Audit and Outcomes.
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www.asr.emilia-romagna.itarea rischio Infettivo
SEPSIS REGIONAL PROGRAM SEPSIS REGIONAL PROGRAM
LaSERAudit and OutcomesAudit and Outcomes
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The “aim” 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
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1) Spreading evidence-based 1) Spreading evidence-based
interventions in the regional interventions in the regional
Hospitals Hospitals :educational programs
2) Systematic Updating of innovations in 2) Systematic Updating of innovations in
sepsis sepsis multidisciplinary groups on sepsis
issues
3) Evaluation of the LASER impact 3) Evaluation of the LASER impact clinical database for ICU patientsclinical Audit in no-ICU patients
4) Evaluation of efficacy/safety profile for 4) Evaluation of efficacy/safety profile for
specific interventions in the clinical specific interventions in the clinical
context.context.
The MethodsThe Methods
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How the regional program:How the regional program:the “REGIONAL NETWORK the “REGIONAL NETWORK
BUILDING” 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,
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How the regional program:How the regional program:““DOCUMENTS” DOCUMENTS”
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Regional program:Regional program:which interventions ?which interventions ?
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the regional program:the regional program:Which interventions…Which interventions…
(Re)-evaluation of(Re)-evaluation ofclinical interventions:clinical interventions:REGIONAL GROUP REGIONAL GROUP RACCOMANDATIONSRACCOMANDATIONSBY ‘GRADE’ METHODBY ‘GRADE’ METHOD
rhAPC CompletedCompleted
Steroids VotingVoting
Glycaemia VotingVoting
Antibiotics AnalysisAnalysis
Immunoglobulins AnalysisAnalysis
Extracorp. therapy
AnalysisAnalysis
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How the regional program:How the regional program: “ “EDUCATION”EDUCATION”
Step # 1 2006-2007Step # 1 2006-2007HOSPITAL TEAMSHOSPITAL 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
ED-Doctors, 18 Infectious disease specialist, 47
Hospital Direction doctor, 46 Nurses.
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Medici Infermieri Totale AUSL Piacenza 144 604 748 AUSL Parma 20 102 122 AO Parma 182 434 616 AO Reggio 49 201 250 AUSL Reggio 58 150 208 AUSL Modena 59 268 327 AO Modena 196 406 602 Hesperia Hospital 10 30 40 AO Bologna 38 255 293 AUSL Bologna 153 499 652 AUSL Imola 132 482 614 AO Ferrara 89 325 414 AUSL Ferrara 47 171 218 AUSL Ravenna * * 270 AUSL Forlì NR NR 0 AUSL Cesena 48 204 252 AUSL Rimini 62 112 174 Totale* 1287 4243 5800
How the regional program:How the regional program: “ “EDUCATION”EDUCATION”Step # 2 2008Step # 2 2008
SINGLE HOSPITAL SINGLE HOSPITAL Doctors
Nurses Totals
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LASER impact: OrganizationLASER impact: Organization
Accessibilità al laboratorio
microbiologico
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.
Possibilità di eseguire emocolture in Pronto
soccorso (PS)
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.
Possibilità di ottenere il lattato in urgenza
La determinazione del lattato in urgenza è possibile in 16 Aziende; la disponibilità di accettazione di richieste in contesti non intensivi è stata introdotta durante il progetto. Un profilo ematochimico “sepsi” in urgenza è stato attivato in 8 Aziende e in alcune di queste è stato introdotto dopo LaSER.
Possibilità di eseguire l’Early Goal Directed
Therapy (EGDT)
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.
Attivazione di percorsi diagnostico/terapeutici
specifici
Sono presenti in 7 Aziende.
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Impatto LASER:Impatto LASER:Identificazione del pazienteIdentificazione del paziente
0,0
20,0
40,0
60,0
80,0
100,0
120,0
140,0
160,0
180,0
200,0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Tass
o p
er
10
0.0
00
abit
anti
1998-2005 2006-2008 Lineare (1998-2005)
Stima della incidenza di sepsi grave nella Regione Emilia-Romagna, 1998-2010:
banca dati SDO
Laser
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Impatto LASER:Impatto LASER:modifiche nei processimodifiche nei processi
0
20
40
60
80
100
120
2005 2006 2007 2008
ESCHERICHIA COLI PSEUDOMONAS AERUGINOSA
KLEBSIELLA PNEUMONIAE ENTEROCOCCUS FAECALIS
ENTEROCOCCUS FAECIUM SERRATIA MARCESCENS
STREPTOCOCCUS PNEUMONIAE STAPHYLOCOCCUS AUREUS
Tasso di batteriemia per 100.000 abitanti, escluse le forme da stafilococchi coagulasi negativi, corinebatteri e da altri possibili contaminanti cutanei, Regione Emilia-Romagna
2005-2008.
Aumento progressivo delle emocolture
eseguite: da 35/100 ricoveri del 2005 a 45/100
ricoveri 2008
Aumento progressivo delle emocolture
positive .
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LASER impact in ICULASER impact in ICU
Clinical Audit in ICU- Pre-Post Intervention- Pre-Post Intervention- 10 ICUs;1000 patients- 10 ICUs;1000 patients
Work in progress
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Clinical Audit in ICU: the DATABASE
LASER impact in ICULASER impact in ICU
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LASER impact in ICULASER impact in ICU
Clinical Audit in ICU: comparison with others
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LASER impact in ICULASER impact in ICU
Clinical Audit in ICU: 6 hours interventions
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General Hospital mortality & General Hospital mortality & Education Sepsis-Targeted (GHEST- Education Sepsis-Targeted (GHEST-
Project)Project)- 6 Hospitals from 2004 to 2008- 6 Hospitals from 2004 to 2008
- departments responsible 80% of H deaths (not only - departments responsible 80% of H deaths (not only
sepsis!) sepsis!)
- 357.270 patients with H length of stay > 24 H- 357.270 patients with H length of stay > 24 H
- H Mortality estimated by multivariate model W/WO - H Mortality estimated by multivariate model W/WO
education education
0
1
2
3
4
5
6
7
1 4 7 1 0 1 3 1 6 1 9 2 2 2 5 2 8 3 1 3 4 3 7 4 0 4 3 4 6 4 9 5 2 5 5 5 8
M e s i
Mo
rta
lità
(%
)
2007 2008
Sepsis education
Estimated mortality without educationObserved Mortality
Mortality
reduction:
•2007: 25 deaths/month
•2008: 32
deaths/month •2 yrs: 692 deaths
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PATIENT DATA
SUGGESTED
THERAPY
GUIDELINES &
INSTRUCTIONS
PATIENT DATA
SUGGESTED
THERAPY
GUIDELINES &
INSTRUCTIONS
LASER impact in ICU:LASER impact in ICU:computer decision support computer decision support
systemsystem
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LASER impact in ICU:LASER impact in ICU:computer decision support computer decision support
systemsystemICU, Modena University HospitalICU, Modena University Hospital
36 patients with septic shock randomized in 36 patients with septic shock randomized in
Manager and Normal groupManager and Normal group
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STEP # 1: CREATE A NETWORK
PROJECT GROUP
2 ICU1 H Administration1 Infectiuos disease1 Internal Medicine
IN-HOSPITAL WORKING GROUP 9 Physicians from dep. with sepsis3 Nurses from dep. with sepsis1 Microbiologist1 Laboratory Physician1 Pharmacist1 Specialist in Quality Assurance1 Head Nurse infection surveillance pr.
IN-HOSPITAL INFECTION
JOINT-COMITEE
HOSPITAL ADMINISTRATION
In-HospitalProgram
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CLINICAL andORGANIZATIONALPROTOCOLS - pre- ICU- ICU
PERORMANCE MEASUREMENT- Sepsis incidence- Sepsis management
EDUCATIONINFORMATION- Hospital Managers - Nurses, Doctors- Patients
AIMSPRIMARY : i) Improve clinical outcome of septic patients in the hospitalSECONDARY:i) Optimize clinical management of septic patient.ii) Reduce ICU and hospital stay of septic patient.iii) Develop research projects on sepsis.
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Subjects & MethodsSubjects & 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)
STEP # 2: EDUCATION
EDUCATION 2004-2008*COURSES: BASIC + ADVANCED + REFRESH PartecipantsDOCTORS 350 (out 500)
NURSES 450 (out 950) From 2007: obligatory education program for all departments
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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 (SEPSIS TEAM) to support clinical decision
4. Measurement - education, process-changes, guidelines application, outcomes
STEP # 3: PROCESS CHANGES
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TEAM SEPSIGENNAIO 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%)
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ICU (2005-2009) severe sepsis/septic shock
BUNDLES COMPLIANCE
6H bundle
24 H bundle
n =195
Perc
en
tag
e o
f p
ati
en
ts
Perc
en
tag
e o
f p
ati
en
ts
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-
10
20
30
40
50
60
70
80
90
gen04-
giu05
lug05-
dic05
gen06-
giu06
lug06-
dic06
gen07-
giu07
lug07-
dic07
gen08-
giu08
lug08-
dic08
Jan 05
Jun 05
July 05
Dec 05
July 06
Dec 06
Jan 06
Jun 06
Jan 07
Jun 07
Jan 08
Jun 08
July 08
Dec 08
July 07
Dec 07
GIViTI
Septic Shock
year SAPS II Mort.H
2005 55±18 62,2
2006 55±18 61,1
SAPS II
50±16 58±27 64±24 56±16 61±16 56±21 65±19 54±17
EDUCATION
SEPSIS TEAM
SAPS II
hospital
30 days
Septic shock n = 85
TI (2005-2008) severe sepsis/septic shock
BUNDLES COMPLIANCE
ICU (2005-2008) severe sepsis/septic shock
MORTALITY
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ICU (2005-2008) septic shock
NO CIRRHOTIC PATIENTS
Girardis et al. Cri Care 2009Girardis et al. Cri Care 2009
Mortality & Sepsis Bundles
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ICU (2005-2008) septic shock
CIRRHOTIC PATIENTS
Mortality & Sepsis Bundles BUNDLES
COMPLETED
BUNDLES
NOT
COMPLETED Patients (n) 15 23
Age (years; mean ±
SD)50 ± 12 52 ± 10
Female (%) 27 30
Cirrhosis aetiology
Viral (n,(%)) 12 (80) 16 (70)
Alcoholic (n, (%)) 1(7) 5 (22)
Other (n, (%)) 2 (13) 2 (9)
MELD score (mean ±
SD)39 ± 11 33 ± 12
Site of infection
Pneumonia (n, (%)) 11 (73) 14 (61)
abdominal infection
(n, (%))6 (43) 9 (39)
Blood (n, (%)) 7 (47) 14 (61)
Urinary tract (n, (%)) 7 (47) 9 (39)
SAPS II (mean ± SD) 68 ± 16 67 ± 22
SOFA (mean ± SD) 17 ± 2 16 ± 3
30 day mortality (n,
(%)) 13 (86,6) 18 (78,2)
Rinaldi et al. J Crit Care 2012Rinaldi et al. J Crit Care 2012
6h bundle6h bundle
24 h bundle24 h bundle
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TakeHomePicture
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LASER impact in ICULASER impact in ICU