area rischio Infettivo SEPSIS REGIONAL PROGRAM

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1 area rischio Infettivo SEPSIS REGIONAL PROGRAM
area rischio Infettivo L A S E R Lotta alla Sepsi in Emilia Romagna SEPSIS REGIONAL PROGRAM LaSER Audit and Outcomes

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

3 Lotta alla Sepsi in Emilia Romagna
E R Lotta alla Sepsi in Emilia Romagna 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.

4 How the regional program: the “REGIONAL NETWORK BUILDING”
L A S E R Lotta alla Sepsi in Emilia Romagna How the regional program: the “REGIONAL NETWORK BUILDING” HOSPITAL ‘SEPSIS TEAM’ (minimal composition): ICU doctor specialist in sepsis ICU Nurse Emergency Department doctor Hospital Organization doctor Infectious disease specialist Nurse dedicated to infection surveillance program in Hospital,

5 How the regional program:
L A S E R Lotta alla Sepsi in Emilia Romagna How the regional program: “DOCUMENTS”

6 Lotta alla Sepsi in Emilia Romagna
Regional program: which interventions ? L A S E R Lotta alla Sepsi in Emilia Romagna

7 Lotta alla Sepsi in Emilia Romagna
E R Lotta alla Sepsi in Emilia Romagna the regional program: Which interventions… rhAPC Completed Steroids Voting Glycaemia Antibiotics Analysis Immunoglobulins Extracorp. therapy (Re)-evaluation of clinical interventions: REGIONAL GROUP RACCOMANDATIONS BY ‘GRADE’ METHOD

8 How the regional program:
L A S E R Lotta alla Sepsi in Emilia Romagna How the regional program: “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 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.

9 How the regional program:
L A S E R Lotta alla Sepsi in Emilia Romagna How the regional program: “EDUCATION” Step # SINGLE HOSPITAL Doctors Nurses Totals

10 L A S E R LASER impact: Organization
Lotta alla Sepsi in Emilia Romagna 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 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.

11 Identificazione del paziente
L A S E R Lotta alla Sepsi in Emilia Romagna Impatto LASER: Identificazione del paziente Stima della incidenza di sepsi grave nella Regione Emilia-Romagna, : banca dati SDO 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 Tasso per abitanti Lineare ( ) Laser

12 modifiche nei processi
L A S E R Lotta alla Sepsi in Emilia Romagna 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 . Tasso di batteriemia per abitanti, escluse le forme da stafilococchi coagulasi negativi, corinebatteri e da altri possibili contaminanti cutanei, Regione Emilia-Romagna

13 Lotta alla Sepsi in Emilia Romagna
E R Lotta alla Sepsi in Emilia Romagna LASER impact in ICU Clinical Audit in ICU - Pre-Post Intervention - 10 ICUs;1000 patients Work in progress

14 Clinical Audit in ICU: the DATABASE
L A S E R Lotta alla Sepsi in Emilia Romagna LASER impact in ICU Clinical Audit in ICU: the DATABASE

15 Clinical Audit in ICU: comparison with others
L A S E R Lotta alla Sepsi in Emilia Romagna LASER impact in ICU Clinical Audit in ICU: comparison with others

16 Clinical Audit in ICU: 6 hours interventions
L A S E R Lotta alla Sepsi in Emilia Romagna LASER impact in ICU Clinical Audit in ICU: 6 hours interventions

17 Lotta alla Sepsi in Emilia Romagna
E R Lotta alla Sepsi in Emilia Romagna General Hospital mortality & Education Sepsis-Targeted (GHEST- Project) - 6 Hospitals from 2004 to 2008 - 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 Estimated mortality without education Observed Mortality Mortality reduction: 2007: 25 deaths/month 2008: 32 deaths/month 2 yrs: 692 deaths Sepsis education 2007 2008

18 computer decision support system
L A S E R Lotta alla Sepsi in Emilia Romagna LASER impact in ICU: computer decision support system

19 computer decision support system
L A S E R Lotta alla Sepsi in Emilia Romagna LASER impact in ICU: computer decision support system ICU, Modena University Hospital 36 patients with septic shock randomized in Manager and Normal group

20 computer decision support system
L A S E R Lotta alla Sepsi in Emilia Romagna LASER impact in ICU: computer decision support system ICU, Modena University Hospital 36 patients with septic shock randomized in Manager and Normal group

21 computer decision support system
L A S E R Lotta alla Sepsi in Emilia Romagna 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 HOSPITAL ADMINISTRATION
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. HOSPITAL ADMINISTRATION In-Hospital Program IN-HOSPITAL INFECTION JOINT-COMITEE

25 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 COURSES: BASIC + ADVANCED + REFRESH
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 * COURSES: BASIC + ADVANCED + REFRESH Partecipants DOCTORS 350 (out 500) NURSES 450 (out 950) From 2007: obligatory education program for all departments

27 1. Establish a multidisciplinary working group
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

28 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%)

29 ICU (2005-2009) severe sepsis/septic shock BUNDLES COMPLIANCE
6H bundle Percentage of patients 24 H bundle Percentage of patients

30 TI (2005-2008) severe sepsis/septic shock BUNDLES COMPLIANCE
ICU ( ) severe sepsis/septic shock MORTALITY TI ( ) severe sepsis/septic shock BUNDLES COMPLIANCE Septic shock n = 85 SEPSIS TEAM EDUCATION SAPS II hospital 30 days 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 SAPS II 50±16 58±27 64±24 56±16 61±16 56±21 65±19 54±17 year SAPS II Mort.H 2005 55±18 62,2 2006 61,1 GIViTI Septic Shock

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

32 Mortality & Sepsis Bundles
ICU ( ) septic shock CIRRHOTIC PATIENTS Mortality & Sepsis Bundles 6h bundle 24 h bundle BUNDLES COMPLETED 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) Urinary tract (n, (%)) 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 2012

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35 Lotta alla Sepsi in Emilia Romagna
E R Lotta alla Sepsi in Emilia Romagna LASER impact in ICU