2. - Ospedale di Circolo e Fondazione Macchi

La mentalita’ d’assistenza al paziente
traumatizzato
TRAUMA
TEAM
Osvaldo Chiara, MD
SC Trauma Team, Dipartimento Trauma Center
A.O. Niguarda, Milano, Italy
[email protected]
Congresso regionale SIMEU, Varese, 26 settembre 2013
Degree in Medicine, july 1978
1979: Stage in Surgical
Intensive Care State
University of NY at Buffalo,
director dr John H Siegel
1982: Stage in Surgical
Intensive Care State
University of MD at
Baltimore, director dr John
H Siegel
SHOCK TRAUMA when life is on the line
Organization
Basic research
Multidisciplinarity
Surgery (gen, ortho, neuro, vasc….)
Critical care
R. Adams Cowley Shock Trauma Center
1993, Baltimore, MD
90s – 20s
eleven periods of
formation at STC
Intergalactic team “B”
1. MOTIVAZIONE E STUDIO
Stefania Cimbanassi, MD
2. CONDIVISIONE
INJURY, 33:553-562, 2002.
255
trauma deaths
185 MALES
( 72.95 % )
age 44 ± 20.7
NP
K 0.87
PP
0.84
69 FEMALES
( 27.05 % )
age 55.9 ± 20.5
DP
0.97
ALL
0.88
Inter-panel agreement (K=1 perfect agreement; K=0 agreement by chance)
SIAT: Sistema Integrato per l’Assistenza al Trauma Maggiore
Ministero della Salute
2004/2005/2006:
Sistema Inclusivo
Level 2: CTZ
centro traumi di
zona
Level 1 : CTS
centro traumi ad
alta specialita’
SUEm
118
Level 3: PST
pronto soccorso
per stabilizzazione
3. FORTUNA
Baltimore 90s
Patient admission
Milano 20s
Baltimore 90s
Shock Room
Milano 20s
TEAM MULTIDISCIPLINARE
Chirurghi, Anestesisti, Ortopedici, Medici
d’Urgenza, Neurochirurghi, Radiologi,
Infermieri in house Altri Specialisti on call
Percorsi
Agosto 2002
TRAUMA
TEAM
- Clinical pathways:
-
protocolli
MS, m 61 yrs
Ped struck
SBP 75 mmHg
EFAST negative
1. Pelvic Binder
2. Pelvic Packing
3. Contrast CT
scan
4. angioembolization
5. External fixation
TRAUMA
TEAM
-
Servizio EU territoriale
Chirurghi
Anestesista o MURG
Ortopedico
Radiologo
Radiologo interventista
Trasfusionista
Infermieri
Tecnici di radiologia
Ausliari
ATLS
- Formazione
- Audit clinici
TRAUMA
TEAM
AUDIT
American College of Surgeons
Advanced
Trauma
Operative
Management
TRAUMA
TEAM
19
Data registry
Health Technology Assessment
159 consecutive pts
positive
negative
ER tests
CTscan
performed 58
pts (36.5%)
Torso injury
47 pts (81%)
TP
No torso
injury 11 pts
(19%) FP
Sensitivity 0.95 PPV 0.79
Specificity 0.88 NPV 0.98
Accuracy 0.91
CTscan not
performed 101
pts (63.5%)
No torso
injury 99 pts
(98%) TN
Torso injury 2
pts (2%)
FN
- 1 pulmonary contusion AIS 2
- 1 small hemothorax
AIS 2
Quality Assessment
109 consecutive pts trauma priority one (red code)
73
D unstable,
ABC stable
Protocol ABCT scan
Time (min) to
CT 14 (11-46)
Time to ICP
135 (55-300)
Time to
craniotomy
60 (55-110)
46
ABC(±D) unstable
ER tests (± CT head) only
Time (min) to laparotomy
59 (22-173)
Time to thoracotomy
44 (7-173)
Time to pelvic packing
52 (25-82)
Time to soft tissue surg.
51 (1-59)
Quality Assessment
*
*
TRAUMA
TEAM
Process Benchmarking
Ps = 1/1(1+e-b) essendo b = b0 + b1(RTS) + b2(ISS) + b3A
90
80
70
60
50
Expected Survival
Observed Survival
40
30
20
10
0
2002 2003 2004 2005 2006 2007 2008 2009 2010
TRAUMA
TEAM
43%
PP+DP
NE
1997-1998 Milano
2002-2004 Niguarda
6.25%
PP
NE
2005-2007 Niguarda
2.35%
PP
NE
4. Trauma Center Implementation:
a process of Clinical Governance
Italy
59,842,000
inhabitants
Active
trauma team
Ospedale dell’Angelo Venezia-Mestre
Ospedale Brotzu Cagliari-Sardegna
Level 1 (CTS)
Level 2 (CTZ)
Level 3 (PST)
requalification projects
POA 2013 2014
Dipartimento Funzionale Niguarda Trauma Center
Chirurgia Trauma Team
Medicina d’Urgenza
Ortopedia
Centro Ustioni
Anestesia Rianimazione
Radiologia Interventistica
Direzione Sanitaria
Direzione Infermieristica
TRAUMA
TEAM
CRITICITA’
- Autoreferenzialita’
- Rapporti con gli specialisti
- Rapporti con le istituzioni
TRAUMA
TEAM
Decreto 8531 del 1 ottobre 2012: SIAT REGIONE LOMBARDIA
CTS
Circolo Varese
Niguarda Milano
Riuniti Bergamo
ESINE
San Gerardo Monza
CLUSONE
Civili di Brescia
San Matteo Pavia
CTZ
Morelli Sondalo
LEGNANO
Fatebene Milano
Ospedale Cremona
Civile Legnano
Manzoni Lecco
S.Carlo Milano
S.Anna Como
S.Raffaele Milano
Policlinico Milano
Poliambulanza Brescia, Humanitas Milano, Citta’ Studi Milano, Moriggia Como
TRAUMA
TEAM
Hospital Discharge Registry: selection criteria
1. ICD9-CM 800.0 e 939.9 e 950.0 e 959.9 (trauma, poisoning
and burns excluded) isolated femoral fractures in aged (> 64
anni) (820.0 – 821.9) excluded
and
2. First admission in rehabilitation hospital or lenght of
hospitalization 0-1 day without death all excluded.
plus
Discharge
code = 4
(deceased)
(a) Mechanical ventilation
(96.70, 96.71, 96.72) or
ward 49 (ICU),
o admission, discharge o (b) tracheostomy (31.1,
31.29) o
r or transit
r
(c) Invasive hemodynamic
monitoring (from 89.60
to 89.69).
TRAUMA
TEAM
Chiara O, et al; World J Emerg Surg 2013; 8:32
Lombardia: severely injured patients with hospital admisssion
2008-2010 (total)
Days LOS
Average
rembursement
€
Total
rembursement
€
n
%_lomb
n dec
%dec
% drgC
Mean
LOS
TOT.
11704
92.38
2829
24.17
55.64
18.53
216877
13˙759
161˙044˙969
2008
3866
91.52
954
24.68
56.54
18.77
72571
13˙684
52˙904˙800
2009
3960
93.21
961
24.27
55.58
18.48
73188
13˙757
54˙478˙959
2010
3878
92.39
914
23.57
54.80
18.34
71118
13˙837
53˙661˙210
Days LOS
Average
rembursement
€
gender
n
% lomb
n dec
%dec
%drgC
Mean
LOS
Male
(%)
7623
(65,13)
91.91
1588
20.83
59.57
19.35
147519
15˙128.02
115˙320˙917
Female
(%)
4081
(34,87)
93.26
1241
30.41
48.30
17.00
69358
11˙204.13
45˙724˙052
TRAUMA
TEAM
Total
rembursement €
Rete Regionale
Ospedale
N casi
% totali
regione
percentuale_dece
duti
030906 Brescia Civili
874
7,46
22,88
030913 Milano Niguarda
842
7,19
17,93
030905 Bergamo Riuniti
622
5,31
17,68
030924 Pavia S.Matteo Mortalita’ 30%
030901 Varese circolo
509
4.34
26,52
448
382,
25,22
030902 Como S.Anna
Mortalita’ media regionale
445
3,80
21,35
030935 Milano S.RaffaeleMortalita’ 20%
397
3,39
25,69
030909 Monza S.Gerardo
382
3,26
25,65
030925 Milano Policlinico
348
2,97
24,43
030908 Cremona Ist. Ospit.
338
2,88
28,11
030281 Legnano Predabissi
313
2,67
27,80
5518
47,14
23,93
Totali
TRAUMA
TEAM
Conclusions
1. Per creare la mentalita’ d’assistenza al traumatizzato occorre
innanzitutto motivazione personale
2. E’ necessario circondarsi delle persone giuste
3. Il percorso di implementazione del trauma center deve avvenire
secondo i principi di clinical governance
4. La disponibilita’ di dati e’ fondamentale per misurarsi, migliorasi
e per rapportarsi con le istituzioni
TRAUMA
TEAM
welcome