Transcript Diapositiva 1 - Policlinico di Modena

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 sequor
Ovidio, Metamorfosi
PROBLEM EXTENT
MISSION
1) 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 AND SEPTIC SHOCK
MORTALITY IS STILL TOO HIGH….. !!!
Italian ICU registry (margherita project, GIVITI group):
SEPTIC SHOCK patients
2006: 158 ICUs, n 2160, H MORTALITY 62,1%
2007: 157 ICUs, n 2347, H MORTALITY 61,2 %
2008: 174 ICUs, n 3067, H MORTALITY 60,9%
2009: 180 ICUs, n 3229, H MORTALITY 59,0%
PROBLEM ANALYSIS
knowledge of disease
mechanisms
Methods
Education
Microorganism effects
Specific processes
Host response
Therapies: mode of action
severe sepsis/
septic shock
MORTALITY IS STILL
TOO HIGH
Therapies available
Microorganism identification
Patient Identification
Effectiveness in vivo
Bundles over- simplification
Other therapies
Materials
Applicability
No process issues
Guidelines
QUALIQUALI
STRUMENTI
STRUMENTI ?
1 ED
Bundles
Pre
Resuscitation (%paz)
0,0
SSC PHASE III
Guidelines application
59 ICUs
Bundles
Pre
Resuscitation (%paz)
5,3
Management (%paz)
10,9
WHY BUNDLES ?
Eight “A” of the
evidence pipeline
JAMA. 1999;282:1458-1465.
1.
2.
3.
4.
5.
6.
7.
8.
Awareness
Acceptance
Applicable
Available
Able
Acted on
Agreed to
Adhered to
if 80% transfer at every stage… just
21% of pts. usage
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 feedback
6.0% 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.
WHY
WHYBUNDLES
BUNDLES
??
59 SPAIN ICUs, 2 months educational program
Severe sepsis and septic shock patients:
n= 859 PRE education (Nov-Dec 2005) (APACHE II 21)
n =1465 POST education (Mar-Jun 2006) (APACHE II 21)
Bundle
Pre
Post
Resuscitation (%pat)
5,3
10,0
Management (%pat)
10,9
15,7
ARR = 4,3%
NNT = 23
Key Points: EDUCATION
2 months education
program
Long term analysis:
23/59 ICUs
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
Key Points:
EDUCATION + PROCESSES
1 ED
Education
+
Process changes
Bundles
Pre
Post
Resuscitation (%paz)
0,0%
51%
Key Points:
NOT ONLY EDUCATION
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: SPECIFIC PROCESSES
SSC PHASE III
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 to support clinical decision
4. Measurement
- education
- process-changes
- guidelines application
- patients outcomes
- economy