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