1. 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

2. Video meliora proboque sed deteriora sequor Ovidio, Metamorfosi

3. PROBLEM EXTENT 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% SEVERE SEPSIS AND SEPTIC SHOCK MORTALITY IS STILL TOO HIGH….. !!! 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

4. 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- simplification Other therapies PROBLEM ANALYSIS Microorganism effects Applicability Patient Identification No process issues Education Specific processes Microorganism identification Therapies available

5. QUALI STRUMENTI QUALI STRUMENTI ?

6. Bundles Pre Resuscitation (%paz) 5,3 Management (%paz) 10,9 SSC PHASE III Guidelines application Bundles Pre Resuscitation (%paz) 0,0 1 ED 59 ICUs

7. WHY BUNDLES ?

8. JAMA. 1999;282:1458-1465. if 80% transfer at every stage… just 21% of pts. usage Eight A of the evidence pipeline 1.Awareness 2.Acceptance 3.Applicable 4.Available 5.Able 6.Acted on 7.Agreed to 8.Adhered to

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. ARR = 4,3% NNT = 23 59 SPAIN ICUs, 2 months educational program 59 SPAIN ICUs, 2 months educational program Severe sepsis and septic shock patients: 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 PrePost Resuscitation (%pat) 5,310,0 Management (%pat) 10,915,7 WHY BUNDLES ?

13. Bundles PrePost 2 monthsPast 1 year Resuscitation (%paz) 6,312,97,3 Management (%paz) 9,419,626,7 H mortality (%paz) 42,538,738,5 2 months education program Long term analysis: 23/59 ICUs Key Points: EDUCATION

15. Bundles PrePost Resuscitation (%paz) 0,0%51% 1 ED Key Points: EDUCATION + PROCESSES Education + Process changes

16. 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

17. SSC PHASE III Key Points: SPECIFIC PROCESSES 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