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Www.asr.emilia-romagna.it area rischio Infettivo SEPSIS REGIONAL PROGRAM LaSER Audit and Outcomes.

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Presentazione sul tema: "Www.asr.emilia-romagna.it area rischio Infettivo SEPSIS REGIONAL PROGRAM LaSER Audit and Outcomes."— Transcript della presentazione:

1 area rischio Infettivo SEPSIS REGIONAL PROGRAM LaSER Audit and Outcomes

2 The aim oThe LASER project has been developed by Agenzia Sanitaria Regionale in the context of PRI-ER program (Research and Innovation program- Emilia Romagna). oThe main objective of LASER project is to promote the transfer in clinical practice of all interventions that can reduce mortality of septic patients

3 1) Spreading evidence-based interventions in the regional Hospitals 1) Spreading evidence-based interventions in the regional Hospitals : educational programs 2) Systematic Updating of innovations in sepsis 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. The Methods

4 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,

5 How the regional program: DOCUMENTS

6 Regional program: which interventions ?

7 the regional program: Which interventions… (Re)-evaluation of clinical interventions: REGIONAL GROUP RACCOMANDATIONS BY GRADE METHOD rhAPCCompleted SteroidsVoting GlycaemiaVoting AntibioticsAnalysis ImmunoglobulinsAnalysis Extracorp. therapyAnalysis

8 How the regional program: EDUCATION EDUCATION Step # 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 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.

9 How the regional program: EDUCATION EDUCATION Step # SINGLE HOSPITAL Doctors Nurses Totals

10 LASER 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 laccessibilità 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 nellambito 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 lEarly 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.

11 Impatto LASER: Identificazione del paziente Stima della incidenza di sepsi grave nella Regione Emilia-Romagna, : banca dati SDO Laser

12 Impatto LASER: modifiche nei processi Tasso di batteriemia per abitanti, escluse le forme da stafilococchi coagulasi negativi, corinebatteri e da altri possibili contaminanti cutanei, Regione Emilia- Romagna Aumento progressivo delle emocolture eseguite: da 35/100 ricoveri del 2005 a 45/100 ricoveri 2008 Aumento progressivo delle emocolture positive.

13 LASER impact in ICU Clinical Audit in ICU - Pre-Post Intervention - 10 ICUs;1000 patients Work in progre ss

14 Clinical Audit in ICU: the DATABASE LASER impact in ICU

15 Clinical Audit in ICU: comparison with others

16 LASER impact in ICU Clinical Audit in ICU: 6 hours interventions

17 General Hospital mortality & Education Sepsis-Targeted (GHEST- Project) - 6 Hospitals from 2004 to departments responsible 80% of H deaths (not only sepsis!) patients with H length of stay > 24 H - H Mortality estimated by multivariate model W/WO education Sepsis education Estimated mortality without education Observed Mortality Mortality reduction: 2007: 25 deaths/month 2008: 32 deaths/month 2 yrs: 692 deaths

18 LASER impact in ICU: computer decision support system

19 LASER impact in ICU: computer decision support system ICU, Modena University Hospital 36 patients with septic shock randomized in Manager and Normal group

20 LASER impact in ICU: computer decision support system ICU, Modena University Hospital 36 patients with septic shock randomized in Manager and Normal group

21 LASER impact in ICU: computer decision support system ICU, Modena University Hospital 36 patients with septic shock randomized in Manager and Normal group

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24 STEP # 1: CREATE A NETWORK PROJECT GROUP 2 ICU 1 H Administration 1 Infectiuos disease 1 Internal Medicine IN-HOSPITAL WORKING GROUP 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 HOSPITAL ADMINISTRATION In-Hospital Program

25 CLINICAL and ORGANIZATIONAL PROTOCOLS - pre- ICU - ICU PERORMANCE MEASUREMENT - Sepsis incidence - Sepsis management EDUCATION INFORMATION - Hospital Managers - Nurses, Doctors - Patients 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.

26 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) STEP # 2: EDUCATION EDUCATION * COURSES: BASIC + ADVANCED + REFRESH Partecipants DOCTORS350 (out 500) NURSES450 (out 950) From 2007: obligatory education program for all departments

27 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 STEP # 3: PROCESS CHANGES

28 TEAM SEPSI GENNAIO 2008 – DICEMBRE 2011 TOTALE PAZIENTI 665 PAZIENTI MESE: 13,7 ± 4,9CHIAMATE PER PAZIENTE: 1, 3 ± 0,9 ATTIVAZIONE CORRETTA : 80%RICOVERI ICU: 222 (33%)

29 ICU ( ) severe sepsis/septic shock BUNDLES COMPLIANCE 6H bundle 24 H bundle n =195 Percentage of patients

30 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 yearSAPS IIMort.H ±1862, ±1861,1 SAP S II 50±1658±2764±2456±1661±1656±2165±1954±17 EDUCATION SEPSIS TEAM SAPS II hospital 30 days Septic shock n = 85 TI ( ) severe sepsis/septic shock BUNDLES COMPLIANCE ICU ( ) severe sepsis/septic shock MORTALITY

31 ICU ( ) septic shock NO CIRRHOTIC PATIENTS Girardis et al. Cri Care 2009 Mortality & Sepsis Bundles

32 ICU ( ) septic shock CIRRHOTIC PATIENTS Mortality & Sepsis Bundles BUNDLES COMPLETED BUNDLES NOT COMPLETED Patients (n) 1523 Age (years; mean ± SD) 50 ± 1252 ± 10 Female (%) 2730 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 ± 1133 ± 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 ± 1667 ± 22 SOFA (mean ± SD) 17 ± 216 ± 3 30 day mortality (n, (%)) 13 (86,6)18 (78,2) Rinaldi et al. J Crit Care h bundle 24 h bundle

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34 T ake H ome P icture

35 LASER impact in ICU


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