miquel gallofré - stroke programme director i “key points” i punti chiave dello stroke...
TRANSCRIPT
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L’ORGANIZZAZIONE DELLA CURA DELLO STROKE IN CATALOGNA Milano, 7 marzo 2014
Miquel Gallofré - Stroke Programme Director
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L’ORGANIZZAZIONE DELLA CURA DELLO STROKE IN CATALOGNA Milano, 7 marzo 2014
Miquel Gallofré - Stroke Programme Director
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I “KEY POINTS”
I punti chiave dello Stroke Programme
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STROKE PROGRAMME
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STROKE PROGRAMME
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DATI GENERALI
7,5 MILIONI DI ABITANTI
PARLAMENTO E GOVERNO AUTONOMI
IL DIPARTIMENTO DELLA SALUTE HA UN BUDGET INDIPENDENTE
DECIDE LE STRATEGIE PRIORITARIE
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PATOLOGIE AD ALTA PREVALENZA
STROKE PROGRAMME
PIANI DIRETTORI
TUMORIMALATTIA CEREBRO-
VASCOLARE
MALATTIA CARDIO-
VASCOLARE
PIANO DIRETTORE MALATTIA CEREBRO-
VASCOLARE
PIANO DIRETTORE
ONCOLOGIA
PIANO DIRETTORE MALATTIA CARDIO-
VASCOLARE
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STROKE PROGRAMME
PIANIFICAZIONE IMPLEMENTAZIONE VALUTAZIONE
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STROKE PROGRAMME
STROKE PROGRAMMEAMMINISTRAZIONE PROFESSIONISTI
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KEY POINT 1:
• L’esistenza d’un programma sull’ictus
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AREE STROKE PROGRAMME
Un responsabile per l’ictus in
ogni ospedale
Un gruppo operativo per
l’ictus in ogni area
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I LIVELLI OSPEDALIERI
Ospedali di riferimento
Ospedali di comunità
Ospedali terziari
Community hospitals
Primary Stroke Centers
Comprehensive Stroke Centers5 (+ da 700)
9 (400 a 700)
35 (40 a 400)
RICOVERI/ANNO/ICTUS
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STROKE CARE NETWORK
ASSEGNARE IL PAZIENTE ALL’OSPEDALE PIÙ ADEGUATO
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CH
CH
CH
CHCH
CH
CH
CHI LIVELLI OSPEDALIERI
PSC
PSC
PSC
PSC CHC
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KEY POINT 2:
• L’esistenza di un programma sull’ictus
• La struttura in rete
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STROKE PROGRAMME
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FASE ACUTA : OBIETTIVO PRINCIPALE
Valutazione esperta/trombolisi il più rapidamente possibile
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STROKE CODE
2006Stroke Code
a tutto il territorio
-Inizio dei sintomi ≤ 6 ore
-RANkin <= 3 e no COMorbidità
-Età <= 80 anni
RAN COM + 23%
2008Valutazione
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STROKE CODE 2013
2013Riformulazione
Stroke Code
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STROKE CODE 2013
ICTUS ?RANKIN<= 3 COMORBILITÀ ++ ?
< 8 h
Età
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CODI ICTUS I FONTS D’ACTIVACIÓ
112 EMS
32 % 18 % 5 % 45 %
OSPEDALI DI COMUNITÀ
ATENZIONE PRIMARIA
OSPEDALI DI RIFERIMENTO
CHI ATTIVÒ LO STROKE CODE 2008
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CODI ICTUS I FONTS D’ACTIVACIÓ
112 EMS OSPEDALI DI COMUNITÀ
ATENZIONE PRIMARIA
OSPEDALI DI RIFERIMENTO
CHI ATTIVA LO STROKE CODE 2013
50 % 18 % 6 % 26 %
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EVOLUZIONE ATTIVAZIONI STROKE CODE
0
2000
4000
6000
8000
10000
12000
2005 2006 2007 2008 2009 2010 2011
RICOVERI ICTUS (esclusi ESA, TIA, MAV)
ATTIVAZIONI
2012 2013
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LE LINIE DE MIGLIORAMENTO 2006 - 2013
2006 2013
TELEICTUSCAMPAGNE TERZIARISMO
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LE CAMPAGNE 2006-2013
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IL TERZIARISMO
Ospedali di riferimento
Ospedali di comunità
Ospedali terziari
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TERZIARISMO PATOLOGIA ISQUEMICA
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PATOLOGIA ISQUEMICA: ATENZIONE URGENTE
3 ospedali di guardia collaborativa dal 2012
I profesionisti vanno
all’ospedale dove è il paziente
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TERZIARISMO EMORRAGIA SUBARCNOIDALE
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EMORRAGIA SUBARCNOIDALE: GUARDIA WEEKEND
Dal 2008, un ospedale rotatorio copre tutta la Catalogna durante il fine settimana
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TELEICTUS 2.0
Ospedale di comunità
Ospedale di riferimento
Ospedale di comunità conTeleictus 2008-2010
24 h
TELEICTUS
Ospedale di comunità con Teleictus 2013
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TELEFONO TELEICTUS
900 100 18624 h
NEUROLOGO VASCOLARE
+ LAP TOP 4GGuardia 24h
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TELEICTUS 2.0
10 Ospedale di comunità
Teleictus Neurologo Vascolare
TAC
Videoconferenza
LAPTOP + 4G
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DOVE VANNO GLI STROKE CODE POSITIVI?
35
CENTRO PIU’ VICINO DOVE SI EFFETTUA LA TERAPIA TROMBOLITICA
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TROMBOLISI IV 24 OSPEDALI
• Lo Stroke Programme ha identificato i percorsi codice ictus + verso l’ospedale adeguato
• Questi percorsi sono diventati un obbligo con un decreto governativo
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N.G.
N.G.
N.G.
N.G.
N.G.
N.G. N.G.
N.G.N.G.
N.G.
NEUROLOGO DI GUARDIA IN 9 OSPEDALI DI RIFERIMENTO
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KEY POINT 3 +++++
• L’esistenza d’un programma sull’ictus• La struttura in rete
• Collaborazione clinici / amministrazione
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I RISULTATI
REGISTRO DI RIPERFUSIONE (SONIIA)
REGISTRO TELEICTUS (TICAT)
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REGISTRI DELLE ATTIVITÀ OBBLIGATORI
40
REGISTRI ON-LINE
COSTRUITI DA PROFESSIONISTI
LO STROKE PROGRAMME MONITORA LA INCLUSIONE
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AUDITORIA ESTERNA DELLA INCLUSIONE
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Newsletter ogni 3 mesi
Informazione pubblica per tutti gli ospedali e professionisti coinvolti
-Lei formano il CAT_SCRC (Catalan Stroke Code Reperfussion Therapy Consortium)
IL FEEDBACK DELLA INFORMAZIONE AI PROFESIONISTI
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TROMBÒLISI INTRAVENOSE - CATALUNYA 2005-2013
0
200
400
600
800
1000
1200
2007
443
2006
329
2005
324
2010
883
2011
964
2009
724
2008
503
Stroke Code in tutto il territorio
2012 2013
10681083
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TERAPIE DI RIPERFUSIONE - CATALUNYA 2005-2013
0
200
400
600
800
1000
1200
2007
443
2006
339
2005
324
2010
883
311
2011
964
289
2009
724
183
2008
503
34
Trombolisi IV EndovascolareREVASCAT CLINICAL TRIAL
2012 2013
1068
323
1083
259
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TASSA TROMBOLISI IV E RIPERFUSIONE / ICTUS ISQUEMICI
ANY TASSO DI TROMBOLISI INTRAVENOSA (%)
TASSO DI TRATTAMENTI DI RIPERFUSIONE (%)
ICTUS ISQUEMICICMBD-HA
2005 3,9 3,9 8264
2006 4,0 4,0 8329
2007 5,0 5,0 8841
2008 6,5 6,7 7790
2009 8,6 9,7 8378
2010 10,6 12,5 8332
2011 11,5 13,0 8391
2012 13,0 14,9 8216
2013 13,2 14,7 8216** Dati provvisori
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TASSA TROMBOLISI IV E RIPERFUSIONE / POPOLAZIONE
2005 2006 2007 2008 2009 2010 2011 2012 2013
4,6
4,6
4,6
4,6
6,0
6,0
7,0
6,7
10,7
9,5
13,6
11,5
14,4
12,6
16,1
14,0
15,9
14,3
TROMBOLISI IV RIPERFUSIONE GLOBAL (IV I ENDOVASC)
Tass
o lo
rdo
per 1
00,0
00 h
ab.
/ an
no
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INDICATORI EFETTIVITÀ GLOBALE CATALONIA rtPA ISOLATE
Referenza * 2011 (n= 804) 2012 (n= 898) 2013 (n= 947)
sICH (SITS-MOST) < 7,7% 4,7% 4,1% 4,7%
mRS 0-1, 3-m > 34,8% 36,6% 40% 38,8%**
mRS 0-2, 3-m > 46.3% 50,1% 51,3% 49,7%**
Mort 3-m < 19% 16,7% 16,1% 15,5%**
** Dati provvisori, mancano follow up’s* Metaanalisi Lancet 2012 Wardlaw et al.
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NOME
DEI
OSPEDALI
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INDICATORI TEMPO GLOBALE CATALONIA rtPA IV
Referenza * 2011 (n= 804) 2012 (n= 898) 2013 (n= 947)
Door to neddle 60 ‘ 55 (41 – 73) 55 (40 – 75) 51 (40 – 70)
Ictus – rtPA < 270 ‘ 144 (105 – 185) 147 (105 – 200) 140 (102 – 195)
** Dati provvisori, mancano follow up’s* Metaanalisi Lancet 2012 Wardlaw et al.
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TELEICTUS 2.0: UN ANNO DI ATTIVITÀ
533 pazienti valutati
94 trombolisi IV
37 derivazione
terziaria
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TELEICTUS 2.0: UN ANNO DI ATTIVITÀ
533 pazienti valutati
94 trombolisi IV
37 derivazione
terziaria
254 Trasferimenti evitati
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EQUITÀ TERRITORIALE: trombolisi iv 2005
p(5): 0.00
p(90): 5.64
Ciutat de Barcelona
r-TPA 2005
Tassi standardizzati trombolísi iv/ 100.000 ab.
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p(5): 0.00
p(90): 23.25
Ciutat de Barcelona
r-TPA 2011/12EQUITÀ TERRITORIALE: trombolisi iv 2011/12
Tassi standardizzati trombolísi iv/ 100.000 ab.
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KEY POINT 4
• L’esistenza di un programma sull’ictus• La struttura in rete• Collaborazione clinici / amministrazione
• Valutazione, feedback e benchmarking
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STROKE PROGRAMME
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GLI OBIETTIVI
Garantire la qualità della atenzione e valutarne gli outcomes
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GLI OBIETTIVI
61
AUDITS DELL’ ICTUS
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GLI OBIETTIVI
62
• Garantire il ricovero nell ospedale più adeguato
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GLI OBIETTIVI
63
AUDITS DELL’ ICTUS
STROKE UNITS
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GLI AUDITS DELL’ICTUS
2006
2008
20112014
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TOP TEN IN 1/ 2 / 3 / 4º AUDITS GLOBAL CATALUNYACo
mpl
imen
t, O
R (IC
95%
)
Glucosa Neuroimatge <24h ictus Deglució Antitrombòtics
1eres<48hMobilització Rehabilitació Prevenció TVP Maneig
dislipèmiaAnticoagulants
FAAntitrombòtics
alta
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MODELLO PIÙ CONDIVISO DI SU:
66
Spazio geografico delimitato
Multidisciplinarietà
Professionisti esperti / addestramento continuo
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SPUNTO DI DISCUSSIONE SULLA SU
67
SEMIINTENSIVITÀ
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SEMIINTESIVITÀ: I DUBBI E LE DISCUSIONE
68
Monitorizzazione vuol dire semiintensività?
Semiintensività, per quanto tempo?
Si devono ricoverare tutti gli ictus in SU semiintensive?
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SEMIINTENSIVITÀ: LE RATIO INFIRMIERE
Reparto normale $ Ratio 1/8 $$ Ratio 1/6 $$$ Ratio ¼ $$$$ Ratio ½ (ESO) $$$$$ +
-
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SEMIINTENSIVITÀ
LEGATA AL LIVELLI OSPEDALIERI
VANTAGGI DELLA STRUCTURA IN RETE
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STROKE UNITS CASISTICA SUFFICIENTE : 8-10 PAZIENTI
A Primi 1-3 giorni: SU
semiintensive solo ictus Dopo : reparto
neurologia
A
A
A
A
A A
A
B Primi 1 a 3 giorni:
SU semiintensive comune
Dopo : reparto neurologia / MI
A
A
B
B B
B
BB
B
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KEY POINT 5 +++
• L’esistenza di un programma sull’ictus• La struttura in rete• Collaborazione clinici / amministrazione• Valutazione, feedback e benchmarking
• Evidenza e logica
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STROKE PROGRAMME
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L’OBIETTIVO IN REABILITAZIONE
Paziente con disabilità nel posto più efficiente
sulla base della intensità della riabilitazione
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TEMPISTICA POST-ICTUS
RANKIN PRECEDENTE NECESSITA’ DI RICOVERO
NIHSS
STATO COGNITIVO
STATO GENERALE/COMORBIDITA
SUPPORTO SOCIO FAMILIARE LUNGODEGENZA
CONVALESCENZA
RHB INTENSIVA
RHB DOMICILIARE / AMBULATORIALE
RISORSE CRITERI
ALTA
MED
IABA
SSA
INTENSITÀ
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IL PROGETTO BARCELONA
I quattro ospedale per acuti hanno centri di riabilitazione collegati e un percorso definito
In funzione del livello di intensità il paziente viene derivato al centro adeguato
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LE LINEE DI LAVORO
77
RHB INTENSIVA 8% Ricoveri
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LE LINEE DI LAVORO
78
RHB INTENSIVA 8% Ricoveri
RHB DOMICILIARE vs CONVALESCENZA 25% Ricoveri
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STROKE PROGRAMME
PROGRAMMA INTEGRALE
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STROKE PROGRAMME & FUNDACIÓ ICTUS
Informazione sull’ictus
Campagne sensibilizzazione
Ricerca
Supporto pazienti/ famiglie
Prevenzione primaria
Fase acuta
Attenzione ospedaliera
Riabilitazione
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KEY POINT 6
• L’esistenza di un programma sull’ictus• La struttura in rete• Collaborazione clinici / amministrazione• Valutazione, feedback e benchmarking• Evidenza e logica
• Approccio integrale
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CATALUNYA ÉS LA REGIÓ MÉS OCCIDENTAL D’ITÀLIA
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STROKE PROGRAMME
MOLTES GRÀCIES!!!