the impact of ssc 2012 on the planning and evaluation of my hospital's performance the impact...
DESCRIPTION
Seminar led by Rui Moreno, MD, PhD, from the Hospital de Santo António dos Capuchos Unidad de Cuidados Intensivos Polivalente Centro Hospitalar de Lisboa Central- Portugal. Abstract: The impact of SSC 2012 on the planning and evaluation of my hospital's performance  The 2012 revision of the Surviving Sepsis Guidelines, together with the new sepsis bundles, will, have a profound impact on the evaluation of the performance of health care systems dealing with the recognition and early treatment of the patient with severe sepsis and septic shock.  With the application and evaluation of the new bundles (now at 3 hours and 6 hours after triage), most of the evaluation will focus in the very early stages of the process of care, when in a significant number of patients will be still in the Emergency Department (ED). This constitutes a major change when compared to the 2008 revision of the SSC, since at that time part of the evaluation was done after 24 hours of diagnosis, when most of the patients was already on the ICU.  An immediate consequence of this will be a major pressure on the ED and in the early connection of the ED with the ICU. This will can be done by creating dedicated admission pathways to patients with suspected severe sepsis and septic shock, to the presence of intensivists on the ED or even to the direct admission (by-passing the ED) to the ICU of theses patients. More than focusing in new therapies, the 2012 revision of the SSC will put the emphasis on the planning and creation of systems able to work fast and flexibly, delivering fast care where it is needed more. Only systems of care able to control and deal with these timing problems will be in condition to offer first quality care to the patient with severe sepsis and septic shock and consequently to have a good evaluation of their performance.TRANSCRIPT
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The impact of SSC 2012 on the panning and evaluation of my
hospital's performance
Critical Care Department - Hospital Vall d'HebronBarcelona, June, 10, 2013
Rui MorenoUCINC, Hospital de São José
Centro Hospitalar de Lisboa Central, E.P.E.
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DECLARATION OF POTENTIAL (REAL) CONFLICT OF INTEREST
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DECLARATION OF POTENTIAL CONFLICT OF INTEREST
• I am not an Anaesthesiologist• I am not and Internist• I am not a surgeon• I am not a GP
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DECLARATION OF POTENTIAL CONFLICT OF INTEREST
• I am not an Anaesthesiologist• I am not and Internist• I am not a surgeon• I am not a GP
I AM AN INTENSIVIST!
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THE PATIENT WITH SEPSIS NEED TEAMS, NOT TRIBES!
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Sepsis = Decomposition, decay
Septic = RottenΣήψις
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DEFINITIONS
Bone et al. Chest. 1992;101:1644;
Wheeler and Bernard. N Engl J Med. 1999;340:207.
SepsisSIRSInfection/Trauma
Severe Sepsis
Sepsis with ≥1 sign of organ failure
Cardiovascular (refractory hypotension)
Renal Respiratory
Hepatic Hematologic
CNS Unexplained metabolic
acidosis
Shock
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800
1,000
1,200
1,400
1,600
1,800
2001 2025 2050
Year
300
400
500
600
Sep
sis
Cas
es (
x103 )
Tota
l US
Pop
ulat
ion
(mill
ion)
Angus DC, et al. JAMA 2000;284:2762-70.Angus DC, et al. Crit Care Med 2001;29:1303-10.
SEVERE SEPSIS IS INCREASING IN INCIDENCE
Severe Sepsis CasesUS Population
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EPIDEMIOLOGY OF SEPSIS IN THE CRITICALLYILL PATIENT
0%
10%
20%
30%
40%
50%
60%
70%
80%
0-1 2-3 4-6 7-10 11-15 16-21
Days in ICU before the study day
Infe
cti
on
rate
N = 6010 1608 1857 1248 1176 742
(EPIC II, 2008)
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?
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?
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INFECTION AND OUTCOME
0,0
5,0
10,0
15,0
20,0
25,0
30,0
35,0
40,0
45,0M
ort
alit
y, %
ICU mortality 13,9 32,2
Hospital mortality 18,7 41,8
No infection Infection
(Moreno et al. 2005 - data from the SAPS 3 study)
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0%
25%
50%
75%
100%
% o
f p
atie
nts
0 2 4 6 8 10 12 14 16 18 20 22 24
SOFA score
Survivors Non-survivors
(R. Moreno, 1997)
EPIDEMIOLOGY OF SEPSIS IN THE CRITICALLYILL PATIENT
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1 OSF
2 OSF
3 OSF
0
20
40
60
80
100
1 2 3 4 5 6 7
ICU
mor
tali
ty (
%)
Number of days in MOF
ORGAN FAILURE AND MORTALITY IN PATIENTS WITH SEPSISAND ORGAN FAILURE
(data from Moreno et al.)
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DECLARATION OF BARCELA2002
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Surviving Sepsis Campaign: Timeline
Barcelona Declaration
SSC Guidelines
2010
???Guidelines
And bundles Revision
2005
NEJM editorial
2004
2002
Guidelines Revision
Phase III starts:IHI partnership
2008 2012
Results published15,000 pts20% RRR
2006
2012--
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Surviving Sepsis Campaign
Guidelines for Management of SevereSepsis/Septic Shock
2004
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Surviving Sepsis Campaign
Guidelines for Management of SevereSepsis/Septic Shock
2008
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Surviving Sepsis Campaign
Guidelines for Management of SevereSepsis/Septic Shock
2012
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Surviving Sepsis — Practice Guidelines, Marketing Campaigns, and Eli LillyPeter Q. Eichacker, M.D., Charles Natanson, M.D., and Robert L. Danner, M.D
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New Policy to deal with Potential Conflicts of Interest
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GRADE PRO: Guideline development process
• Prioritize problems (and define specific question(s)• Perform systematic review• Summarize the evidence in evidence profiles (summary of
findings tables)• Judge which outcomes are critical • Judge overall quality of evidence• Judge balance of benefits and downsides• Generate recommendation• Judge strength of recommendation
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42
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43
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4.5 potentials for a mishap per operation
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NURSING WORK
Gets IV bags,
Checks
orders in binder
13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00
Hangs IV
IV push Oral meds,
topical cream
Checks updates
in computer
Hangs IV
Planning for new shift
Checks
orders in binderHangs IV
Hangs IV
Hangs IV
Oral meds
IV push
Oral meds
Insulin
Hangs IV
Pain med
Checks updates
in computer
Topical cream
Other RN needs binder
Nursing home assessment
Narcotic keys
Staffing
IV pump alarm
Fingerstick
machine
calibration
Hand off assessment
IV pump alarm
Narcotic meds too many to put in cart
Narcotic keys
Other RN leaves floor
Signature for narcotics
Move patient to new bed
Water for patient
New nursing assistant arrives
MD asks to tape down IV
LPN she is covering
Children on floor
Patient risk of falling
Other RN returns
Hang IV for her
Pain med request
BP machine problems
Dinner
Patient moved up in bed
Water for patient
Fingerstick machine
IV pump alarm
Beds
Weigh
patient
Staffing
Other RN
dinner
Hang IV
IV pump alarm
Cart
Wife of patient
Emily S. Patterson PhD
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Surviving Sepsis Campaign
Guidelines for Management of SevereSepsis/Septic Shock
Version 2012
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Direct medical costs
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van Beeck et al. J Trauma 1997;42:1116
TRAFFIC INJURIES
0 10 20 30 40 50 60 70 80 900
10
20
Age in years
Mill
ion
s of
US
$Male
Female
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van Beeck et al. J Trauma 1997;42:1116
OCCUPATIONAL INJURIES
0 10 20 30 40 50 60 70 80 900
1
2
3
4
5Male
Female
Age in years
Mill
ion
s of
US
$
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DOMESTIC INJURIES
0 10 20 30 40 50 60 70 80 900
10
20
30
40
50
60
70
80
90
100
Age in years
Mill
ion
s of
US
$
van Beeck et al. J Trauma 1997;42:1116
Male
Female
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1990 1991 1992 1993 1994 19952000
2200
2400
2600
2800
3000
3200
3400
3600
Years
Tot
al e
xpen
ditu
re in
acu
te c
are
- M
illi
on E
uro
Denmark
TOTAL EXPENDITURE IN HEALTH CARE
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Direct medical costs
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IF WE WANT TO AVOID A DISASTEROUR FOCUS SHOULD BE ON
THE EVALUATION AND OPTIMIZATIONOF THE SERVICES WE PROVIDE
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HOW (UN)RELIABLE IS MEDICINE?
• 10-1 means that 1 to 9 times out of 10 the intended actions fail to produce the desired results or are defective. An example is if I have a 80% compliance with giving appropriate DVT prophylaxis there are 2 defects in our process in every 10 patients
• 10-2 means that 1 to 9 times out of 100 the intended action or results fail or are defective. An example is if I have 96% compliance with giving appropriate DVT prophylaxis there will be 4 defects in our process in every 100 patients
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Average Percent
High Income
Zip Codes
Low Income
Zip Codes
Expected in One Year
Diabetic Eye Exams
47,9 53,2 44,9 100,0
Hgb A1c Monitoring
55,9 59,5 50,9 100,0
Mammography Screening
46,7 50,8 39,8 100,0
Colon Cancer Screening
9.0 (45%) 10,3 8,0 20,0
Influenza Vaccine 46,5 50,8 41,5 100,0Pneunococcal
Vaccine8 (80%) 8,7 7,3 10,0
Pham HH. Delivery of Preventive Services. JAMA
2005; 294:473-481
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WHAT ARE OUR EXPECTATIONS OF RELIABILITY IN OTHER INDUSTRIES?
1. How many of you would put up with your automobile not starting two out of ten starts?
2. How many of you would fly commercially, if airplanes crashed or abandoned the trip one out of every ten flights?
3. How many of you would frequent a restaurant that served contaminated food three times out of every ten meals?
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HEALTH CARE RELIABILITIES
(Un)Reliability Outcome/Process
10-1
Beta blockers and ASA in Acute MIHgA1c tested at least 3 times every 2 yrs Mammograms, ImmunizationLower Vt in ALI Patients.
10-2Serious adverse events in hospitalDeaths in high risk surgery
10-3Neonatal mortalityGeneral surgery deaths
10-4 Deaths in routine anesthesia
10-5 Blood Banking
10-6 ?
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1996 1997 1998 1999 2000 2001 20020
5
10
15
20
25
30
35
10.3 10.5 10.3 9.6 8
7.7 6.9
2 2 2 2
12
21
31
Median Vt ml/kgMoving average (Median Vt ml/kg)% of ARDS Patients Recieving 6 ml/kg VtMoving average (% of ARDS Patients Recieving 6 ml/kg Vt)
ARDS Network Paper Published NEJM May 2000
Death deceased from 40% to 31% p= 0.007
(Am J. Respir & CCM 2004; 169 supp:A256)
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1996 1997 1998 1999 2000 2001 20020
5
10
15
20
25
30
35
10.3 10.5 10.3 9.6 8
7.7 6.9
2 2 2 2
12
21
31
Median Vt ml/kgMoving average (Median Vt ml/kg)% of ARDS Patients Recieving 6 ml/kg VtMoving average (% of ARDS Patients Recieving 6 ml/kg Vt)
ARDS Network Paper Published NEJM May 2000
Death deceased from 40% to 31% p= 0.007
Two Years after publishing the evidence,
‘7’ of 10 patients are NOT receiving best care
(Am J. Respir & CCM 2004; 169 supp:A256)
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TIDAL VOLUME IN THE ICU’S
Luhr 1999 Esteban 2000
Esteban 2002
Esteban 2002
ALIVE 2004 SAPS30
2
4
6
8
10
12mL/kg
(João Gouveia et al. Data from the SAPS 3 study)
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PEEP IN THE ICU’S
0
2
4
6
8
10
12
14
Luhr 1999 Esteban2000
Esteban2002
Esteban2002
ALIVE 2004 SAPS3
cmH2O
(João Gouveia et al. Data from the SAPS 3 study)
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We demand the right to make bad choices.
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Bad choices yield bad results
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4.5 potentials for a mishap per operation
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NURSING WORK
Gets IV bags,
Checks
orders in binder
13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00
Hangs IV
IV push Oral meds,
topical cream
Checks updates
in computer
Hangs IV
Planning for new shift
Checks
orders in binderHangs IV
Hangs IV
Hangs IV
Oral meds
IV push
Oral meds
Insulin
Hangs IV
Pain med
Checks updates
in computer
Topical cream
Other RN needs binder
Nursing home assessment
Narcotic keys
Staffing
IV pump alarm
Fingerstick
machine
calibration
Hand off assessment
IV pump alarm
Narcotic meds too many to put in cart
Narcotic keys
Other RN leaves floor
Signature for narcotics
Move patient to new bed
Water for patient
New nursing assistant arrives
MD asks to tape down IV
LPN she is covering
Children on floor
Patient risk of falling
Other RN returns
Hang IV for her
Pain med request
BP machine problems
Dinner
Patient moved up in bed
Water for patient
Fingerstick machine
IV pump alarm
Beds
Weigh
patient
Staffing
Other RN
dinner
Hang IV
IV pump alarm
Cart
Wife of patient
Emily S. Patterson PhD
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Revised SSC Bundles
• Based on 2012 SSC guideline Revision• Utilizing analysis of 28,000 pt in the SSC
database• New software to be developed• No industry funding utilized in revising guidelines or
bundles
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Revised SSC Bundles
• Management bundle dropped• IPP: High compliance at outset of study
• No significant change in compliance• Glucose:
• Clouded by controversy• Steroids:
• OR > 1.0 in SSC analysis• rhAPC:
• Significant OR for survival but after the results of PROWESS-SHOCK was withdraw from all markets
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Sepsis Resuscitation Bundle (To be started immediately and completed within 3 hours)
• Serum lactate measured in 3 hours.• Blood cultures obtained prior to antibiotic
administration.• Minimize time to administration of broad-spectrum
antibiotics with a maximum of 3 hours. • In the event of hypotension and/or lactate >
3mmol/L, deliver a minimum bolus of 30 ml/kg of crystalloid (or colloid equivalent) within 1 hour.
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Septic Shock Bundle (To be started immediately and completed within 6 hours)
• Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg.
• In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate > 4 mmol/L (36 mg/dl):
• Insert central line• Achieve central venous pressure (CVP) of > 8 mm Hg.• Achieve central venous oxygen saturation (ScvO2) of >
70%.
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Role of Collaboration
ICUED
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SOAP AND SEPSIS-ANALYZING WHAT COMES OUT IN THE WASH
• From the data they obtained, Dr. Vincent and colleagues make a number of observations:• First, sepsis occurs frequently, being reported in almost
40% of patients in the ICU• Second, the frequency of sepsis varies markedly
between countries, and countries with higher frequencies of sepsis have higher mortality rates among all patients admitted to the ICU.
• Finally, they report that the presence of a positive cumulative fluid balance over the first 72 hrs from the onset of sepsis is, among other variables, independently associated with higher ICU mortality.
Warren Lee & Niall Ferguson. Critical Care Medicine2006; 34:552-554)
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SOAP AND SEPSIS-ANALYZING WHAT COMES OUT IN THE WASH
Warren Lee & Niall Ferguson. Critical Care Medicine2006; 34:552-554 )
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SOAP AND SEPSIS-ANALYZING WHAT COMES OUT IN THE WASH
• Data demonstrate that the mortality rate from organ failure was the same for patients with severe sepsis as it was for those without sepsis, suggesting that organ dysfunction, rather than infection per se, is the key.
• What could account for these findings?• ...difference in case-mix and ICU admission
threshold• ...the higher mortality rate in the ICUs with higher
sepsis prevalence might be a marker of overtaxed resources in the ICU or during pre-ICU care
• ... it is tempting to speculate that baseline differences in antibiotic use between ICUs may have contributed both to the differences in the reported frequency of sepsis and to the mortality rates observed.
Warren Lee & Niall Ferguson. Critical Care Medicine2006; 34:552-554 )
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(Crit Care Med 2006; 34:211–218)
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FINDING OUT WHAT WE DO IN THE ICUMitchell M. Levy, MD, FCCM
• This task force represents a change in focus, not only for SCCM in particular but for the field of critical care in general.
• ...for a long time, SCCM, along with other critical care societies, focused on the model of critical care delivery.
• Regardless of the model of critical care delivery, the most important aspect of critical care is the quality of care patients receive in a given ICU.
• For many years, the assessment of this quality was based on measuring and reporting outcomes of care.
• Now, finally, there is a growing understanding that paying attention to the details or process of care is the truly essential aspect of quality measurement in the ICU. (Crit Care Med 2006; 34:227–228)
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FINDING OUT WHAT WE DO IN THE ICUMitchell M. Levy, MD, FCCM
• Curtis et al., at the direction of SCCM, have provided clinicians in critical care units with a blue-print or mirror for self-examination. The next step is for critical care clinicians to look into that mirror and decide whether or not we like what we see.
(Crit Care Med 2006; 34:227–228)
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NEGOVSKY IBSEN SAFAR
WE HAVE STRONG SCIENTIFIC FOUNDATIONS TO OUR SPECIALITY
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FROM REANIMATION TO INTENSIVE CARE MEDICINE
REANIMATION INTENSIVE CARE
INTENSIVE CARE MEDICINE
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20 years ago Dr Bill Knaus acknowledged:
• It’s the human resources of the ICU TEAM, their organization and distribution, and how we apply technology consistently, NOT the genius of individuals or the treatment “magic bullet” that leads to EFFICIENT and EFFECTIVE ICU.
Knaus et al Annals Int Med 1986: 104.410
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DISEASES THAT MADE THE ICU
Polio: Mortality 60% to 20% ??? (but just in 2 or 3 countries)
Tetanus: Mortality approaches Zero
Guillian-Barré syndrome: Mortality approaches Zero
Acute organophosphate poisoning: almost disapeared
Most of the mortality relates to co-morbidity and complications of ICU treatment.
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DEVELOPMENT AS A CHALENGE
• Education and training of new professionals.• Training in Intensive care of other professionals.• Better much between resources and workload.• The flux of patients within the hospital: admission
and discharge policies, readmissions.• Patient safety: prevention of adverse events.• Organisative aspects: leadership, communication,
team-work.
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Current and projected workforce requirements for care of the critically ill.Angus D et al. JAMA 2000 : 284; 2762-70
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RETIRE FROM ICU CARE AT 77 YEARS:
(Angus et. Al, JAMA 2002)
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0
50
100
150
200
250
300
350
400IC
U a
dm
issio
ns,
thousan
ds
2001 2006 2011 2016 2021 2026 2031Year
At 2006 ratesModelling trend
ICN
AR
CIn
tensi
ve C
are
Nati
onal A
udit
& R
ese
arc
h C
entr
e 160% increase in demand over 10 years.
Projected ICU Bed Day RequirementsRowan K et al
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INTENSIVE CARE IS NOT ABOUT MACHINES
IT IS ABOUT PEOPLE
IT IS ABOUT ORGANIZATION
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127
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129
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NUMBER OF INTENSIVE CARE BEDS PER 100.000 INHABITANTS
0 2 4 6 8 100
5
10
15
20
25
30
Portugal
USA
França
UK
Canadá
Bélgica
Alemanha
HolandaEspanha
130
nº d
e ca
mas
de
Med
icin
a In
tens
iva
por
100.
000
habi
tant
es
Países(Data from Wunsch et all, 2008)
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NUMBER OF INTENSIVE CARE BEDS PER 100.000 INHABITANTS
0 2 4 6 8 10 12 140
5
10
15
20
25
Portugal
USA
França
UK
Canadá
Suécia
Holanda
Espanha
CroáciaBélgica
Alemanha
Trinidá e Tobago
131
Países
nº d
e ca
mas
de
Med
icin
a In
tens
iva
por
100.
000
habi
tant
es
(Data from Adhikari et al., 2010)
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132
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Total n° Acute Care Beds
• ≈2 millions
Total N° IC Beds
• ≈ 60.000
IC Beds/AC Beds %
• ≈3%
Acute and intensive care beds in Europe…….
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(Andrew Rhodes &Rui Moreno, 2012, ICM)
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Acute care bedsAcute care hospital
beds / 100,000 population.
Total number of ICU and IMCU care beds
Total Adult ICU and IMCU beds / 100,000
populationAdult ICU beds as % of all
acute care beds %>65
Andorra 188 224 6 7.1 3.2 13Austria 48446 635 1833 21.8 3.4 18.2Belgium 50156 456 1900 17.3 3.8 18Bulgaria 57460 766 2154 28.7 3.7 18.2Croatia 15629 353 650 14.7 4.2 16.9Cyprus 2813 350 92 11.4 3.3 10.4Czech Republic 91068 865 1227 11.6 1.3 16.3Denmark 17124 308 372 6.7 2.2 17.1Estonia 5096 380 262 19.5 5.1 17.7Finland 12442 231 329 6.1 2.6 17.8France 232821 358 10540 16.2 4.5 16.8Germany 469791 575 23,890 29.2 5.1 20.6Greece 44411 392 680 6 1.5 19.6Hungary 41574 416 1374 13.8 3.3 16.9Iceland 1169 367 29 9.1 2.5 12.7Ireland 12202 272 289 6.5 2.4 11.6Italy 201932 333 7,550 12.5 3.7 20.3Latvia 11833 531 217 9.7 1.8 16.9Lithuania 17061 526 502 15.5 2.9 16.5Luxemberg 2511 491 127 24.8 5.1 14.9Netherlands 56085 337 1065 6.4 1.9 15.6Norway 13639 277 395 8 2.9 16Poland 156662 410 2635 6.9 1.7 13.7Portugal 31722 298 451 4.2 1.4 18Romania 108611 507 4574 21.4 4.2 14.8Slovakia 32560 599 500 9.2 1.5 12.8Slovenia 7656 373 131 6.4 1.7 16.8Spain 124194 269 4479 9.7 3.6 17.1Sweden 26131 278 550 5.8 2.1 19.7Switzerland 28096 357 866 11 3.1 17United Kingdom 147809 237 4114 6.6 2.8 16.5
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Total size of Population Gross Domestic Product (GDP)
($millions)Gross Domestic Product (GDP) per
inhabitant ($)Total expenditure on health as a %
of GDP
Andorra 84082 2893 34,407 7.7Austria 8404252 377,382 44,904 8.6Belgium 11007020 467,779 42,498 8.2Bulgaria 7504868 47,702 6,356 4.4Croatia 4425747 60,834 13,745 7.8Cyprus 804435 23,174 28,808 6.0Czech Republic 10532770 192,030 18,232 6.9Denmark 5560628 309,866 55,725 9.8Estonia 1340194 19,253 14,366 5.3Finland 5375276 239,177 44,496 6.8France 65075310 2,562,742 39,381 9.2Germany 81748892 3,286,451 40,202 8.9Greece 11329618 305,415 26,957 5.8Hungary 9986000 130,421 13,060 5.2Iceland 318452 12,594 39,548 7.9Ireland 4480176 206,985 46,200 7.2Italy 60626508 2,055,114 33,898 7.4Latvia 2229641 24,013 10,770 8.1Lithuania 3244601 36,370 11,209 7.8Luxemberg 511840 54,950 107,358 4.1Netherlands 16654979 780,668 46,873 5.5Norway 4920305 412,990 83,936 8.1Poland 38200037 469,401 12,288 5.3Portugal 10636979 229,154 21,543 5.7Romania 21413815 161,629 7,548 5.4Slovakia 5435273 87,450 16,089 6.0Slovenia 2050189 47,733 23,282 6.8Spain 46152926 1,409,946 30,549 7.0Sweden 9415570 458,725 48,720 8.2Switzerland 7866500 527920 67,110 6.8United Kingdom 62435709 2,250,209 36,040 8.2
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(Andrew Rhodes & Rui Moreno, 2012, ICM)
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(Andrew Rhodes & Rui Moreno, 2012, ICM))
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(Andrew Rhodes & Rui Moreno, 2012, ICM)
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(Andrew Rhodes & Rui Moreno, 2012, ICM)
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(Andrew Rhodes & Rui Moreno, 2012, ICM)
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WE HAVE ARRIVED
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DEVELOPMENT AS AN
OPPORTUNITY
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• Intensivist model (closed) reduced mortality. (OR: 0.71 95%CI 0.62-0.82)
• Intensivist model (closed) reduced length of stay
Pronovost et al. JAMA; 2002-2151
Physician staffing patterns and clinical outcomes in critically ill patients.
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Most Positive Factors Most Negative factors
Intellectual stimulation Lack of leisure time
Treating acutely ill patients Stress among faculty
Application of complex physiology
Treating chronically ill patients
Procedure orientated Inconsistent with my personality
Dealing with end-of-life issues
Dealing with complex ethical issues.
Attitudes and Perceptions of Internal Medicine Residents Regarding Pulmonary and Critical Care Subspecialty Training.Lorin S et al. Chest 2005 : 127; 630-6.
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“Beauty comes first. Victory is secondary. What matters is joy.”
Sócrates Brasileiro Sampaio de Souza Vieira de Oliveira
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147
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STRESSED INTENSIVISTS ?
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“The physician must be able to tell the antecedents, know the present, and foretell the future- must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.
The art consists in three things- the disease, the patient, and the physician. The physician is the servant of the art, and the patient must combat the disease along with the physician.”
Hippocrates, in Epidemics, Book 1, section 11
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Gràcies