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www.asr.emilia-romagna.it area rischio Infettivo. Lotta alla Sepsi in Emilia Romagna. L A S. E R. SEPSIS REGIONAL PROGRAM LaSER Audit and Outcomes. Lotta alla Sepsi in Emilia Romagna. L A S. E R. The “aim”.

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  1. www.asr.emilia-romagna.it area rischio Infettivo Lotta alla Sepsi in Emilia Romagna L A S E R SEPSIS REGIONAL PROGRAM LaSER Audit and Outcomes

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

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

  7. Lotta alla Sepsi in Emilia Romagna L A S E R the regional program: Which interventions… (Re)-evaluation of clinical interventions: REGIONAL GROUP RACCOMANDATIONS BY ‘GRADE’ METHOD

  8. Lotta alla Sepsi in Emilia Romagna L A S E R How the regional program: “EDUCATION” Step # 1 2006-2007 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. Lotta alla Sepsi in Emilia Romagna L A S Nurses Totals Doctors E R How the regional program: “EDUCATION” Step # 2 2008 SINGLE HOSPITAL

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

  11. Lotta alla Sepsi in Emilia Romagna L A S E R 200,0 180,0 160,0 140,0 120,0 Tasso per 100.000 abitanti 100,0 80,0 60,0 40,0 20,0 0,0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 1998-2005 2006-2008 Lineare (1998-2005) Impatto LASER: Identificazione del paziente Stima della incidenza di sepsi grave nella Regione Emilia-Romagna, 1998-2010: banca dati SDO Laser

  12. Lotta alla Sepsi in Emilia Romagna L A S E R Impatto LASER: modificheneiprocessi • 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 100.000 abitanti, escluse le forme da stafilococchi coagulasi negativi, corinebatteri e da altri possibili contaminanti cutanei, Regione Emilia-Romagna 2005-2008.

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

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

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

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

  17. Lotta alla Sepsi in Emilia Romagna L A S E R General Hospital mortality & Education Sepsis-Targeted (GHEST- Project) - 6 Hospitals from 2004 to 2008 - departments responsible 80% of H deaths (not only sepsis!) - 357.270 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: 25deaths/month • 2008: 32 deaths/month • 2 yrs: 692 deaths Sepsis education 2007 2008

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

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

  20. STEP # 1: CREATE A NETWORK • 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. • PROJECT GROUP • 2 ICU • 1 H Administration • 1 Infectiuos disease • 1 Internal Medicine HOSPITAL ADMINISTRATION In-Hospital Program IN-HOSPITAL INFECTION JOINT-COMITEE

  21. 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.

  22. 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 2004-2008* COURSES: BASIC + ADVANCED + REFRESH Partecipants DOCTORS 350 (out 500) NURSES 450 (out 950) From 2007: obligatory education program for all departments

  23. 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

  24. 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%)

  25. ICU (2005-2009) severe sepsis/septic shockBUNDLES COMPLIANCE n =195 6H bundle Percentage of patients 24 H bundle Percentage of patients

  26. ICU (2005-2008) severe sepsis/septic shockMORTALITY TI (2005-2008) severe sepsis/septic shockBUNDLES COMPLIANCE SAPS II hospital Jan 05 Jun 05 July 05 Dec 05 Jan 06 Jun 06 July 06 Dec 06 Jan 07 Jun 07 July 07 Dec 07 Jan 08 Jun 08 July 08 Dec 08 30 days Septic shock n = 85 SEPSIS TEAM EDUCATION GIViTI Septic Shock

  27. ICU (2005-2008) septic shock NO CIRRHOTIC PATIENTS Mortality & Sepsis Bundles Girardis et al. Cri Care 2009

  28. ICU (2005-2008) septic shock CIRRHOTIC PATIENTS Mortality & Sepsis Bundles 6h bundle 24 h bundle Rinaldi et al. J Crit Care 2012

  29. TakeHomePicture

  30. Lotta alla Sepsi in Emilia Romagna L A S E R LASER impact in ICU

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