Journal Club: la gestione in pillole SOPRAVVIVERE ALLA SEPSI: I PRIMI 5 ANNI

1. Journal Club: la gestione in pilloleSOPRAVVIVERE 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

2. Video meliora proboque sed deteriora sequorOvidio, Metamorfosi

3. 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%

4. 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 Guidelines Effectiveness in vivo Microorganism identification Bundles over- simplification Patient Identification Other therapies Materials Applicability No process issues

5. QUALI STRUMENTI QUALI STRUMENTI ?

6. SSC PHASE III Guidelines application 1 ED 59 ICUs

7. WHY BUNDLES ?

8. Eight “A” of the evidence pipeline • Awareness • Acceptance • Applicable • Available • Able • Acted on • Agreed to • Adhered to JAMA. 1999;282:1458-1465. if 80% transfer at every stage… just 21% of pts. usage

11. 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.

12. WHY BUNDLES ? WHY 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) ARR = 4,3% NNT = 23

13. Key Points: EDUCATION 2 months education program Long term analysis: 23/59 ICUs

15. Key Points: EDUCATION + PROCESSES 1 ED Education + Process changes

16. 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.

17. 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