www.asr.emilia-romagna.itarea rischio Infettivo

SEPSIS REGIONAL PROGRAM SEPSIS REGIONAL PROGRAM

LaSERAudit and OutcomesAudit and Outcomes

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

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

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,

How the regional program:How the regional program:““DOCUMENTS” DOCUMENTS”

Regional program:Regional program:which interventions ?which interventions ?

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

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.

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

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.

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

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 .

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

Clinical Audit in ICU: the DATABASE

LASER impact in ICULASER impact in ICU

LASER impact in ICULASER impact in ICU

Clinical Audit in ICU: comparison with others

LASER impact in ICULASER impact in ICU

Clinical Audit in ICU: 6 hours interventions

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

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

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

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

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.

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

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

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%)

ICU (2005-2009) severe sepsis/septic shock

BUNDLES COMPLIANCE

6H bundle

24 H bundle

n =195

Perc

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gen04-

giu05

lug05-

dic05

gen06-

giu06

lug06-

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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

ICU (2005-2008) septic shock

NO CIRRHOTIC PATIENTS

Girardis et al. Cri Care 2009Girardis et al. Cri Care 2009

Mortality & Sepsis Bundles

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

TakeHomePicture

LASER impact in ICULASER impact in ICU