What are the solutions for the problems in lower respiratory infections? : GEORGIA

1. What are the solutions for the problems in lower respiratory infections?: GEORGIA Georgian Respiratory Association Ivane Chkhaidze, MD, PhD, Professor, President of the Georgian Respiratory Association

2. Georgian way • Development guidelines; recommendations to rationalize the use of antibiotics; recommend measures to improve CAP outcome; • Provide permanent training process in PHC facilities and hospitals; • State program “Development of Hospital Sector in Georgia” • GRA initiative to create Respiratory Medicine Centre in the frame of the State program.

3. Development and implementation of the clinical guidelines Over the past decade, clinical guidelines have increasingly become a familiar part of clinical practice. Every day, clinical decisions at the bedside, rules of operation at hospitals and clinics, and health spending by governments and insurers are being influenced by guidelines.

4. Development and implementation of the clinical guidelines Clinical guidelines may offer concise instructions on which diagnostic or screening tests to order, how to provide medical or surgical services, how long patients should stay in hospital, or other details of clinical practice.

5. Development and implementation of the clinical guidelines The broad interest in guidelines has its origin in issues that most healthcare systems face: rising healthcare costs; more expensive technologies; variations in service delivery among providers, hospitals, and geographical regions; the desire of healthcare professionals to offer, and of patients to receive, the best care possible. Clinicians, policy makers, and payers see guidelines as a tool for making care more efficient and for closing the gap between what clinicians do and what scientific evidence supports.

6. Potential benefits for patients For patients the greatest benefit that could be achieved is to improve health outcomes. Guidelines that promote interventions of proved benefit and discourage ineffective ones have the potential to reduce morbidity and mortality and improve QoL. Guidelines can also improve the consistency of care. Patients with identical clinical problems receive different care depending on their clinician or hospital. Guidelines making it more likely that patients will be cared for in the same manner regardless of where or by whom they are treated.

7. Potential benefits for healthcare professionals Clinical guidelines can improve the quality of clinical decisions. They offer explicit recommendations for clinicians who are uncertain about how to proceed, overturn the beliefs of doctors accustomed to outdated practices, improve the consistency of care. Evidence based guidelines clarify which interventions are of proved benefit and document the quality of the supporting data.

8. Creating of guidelines in Georgia In the beginning 2006, the MoH of Georgia offered to professional associations to provide Medical guidelines for different level of health care services: for PHC and for hospitals.

9. Creating of guidelines in Georgia In October 2006 the first ten guidelines had been approved be the State Council, among them were 4 guidelines created by the GRA: AB, Pneumonia, ARI and Chronic cough.

10. How to Improve Outcome in Patients with CAP The optimum outcome in CAP can be achieved by careful risk stratification using prediction rules together with appropriate antibiotic regimens. The mainstay of community-acquired pneumonia prevention is influenza and pneumococcal immunization. Promotion of smoking cessation will also help reduce the incidence of CAP. Talwar A. Curr Opin Pulm Med. 2007 May;13(3):177-85

11. How to Improve Outcome in Patients with CAP • Separate low-Risk from high-risk CAP patients; • Appropriate choice of outpatient treatment; • Timely and appropriate antibiotic therapy; • Determining medical stability before discharge. Mark W. Stanton, M.A. AHRQ Pub. No. 02-0033. 2002 Houck PM, Arch Int Med, 2004

12. I. Separate Low-Risk from High-Risk CAP Patients The Pneumonia Severity Index (PSI), helps physicians determine whether CAP patients should be treated at home or in a hospital. Using a two-step process, the PSI provides a way for clinicians to measure the severity of a patient's illness and predict the risk of mortality. Patients classified in risk classes I-III are considered a low enough risk either for home treatment or abbreviated inpatient care (a 1-day hospital stay). Patients in risk classes IV and V should be hospitalized.

13. PSI Separates Low-Risk from High-Risk CAP Patients During the first step of the physician’s decision process, an initial history and physical examination are performed. The patient’s risk level is evaluated using factors such as age, presence of other illnesses (tumor, renal and liver disease, etc). The physician then determines mental status, a pulse rate, a respiratory rate, systolic blood pressure, and temperature. Patients can be assigned to the lowest risk class (I) do not require expensive lab tests.

14. PSI Separates Low-Risk from High-Risk CAP Patients For patients not assigned to the lowest risk class (I), the second step is used to further determine risk of death or other adverse outcomes. Blood tests determine the extent and effects of pneumonia by measuring sodium, glucose, and blood urea nitrogen as well as arterial pH and hematocrit. An x-ray is used to determine how many lobes are affected and whether there is pleural effusion. On the basis of these results, patients are placed in a risk category ranging from II to V.

15. Fine MJ, et al. N Engl J Med 1997

16. II. Outpatient Treatment Outpatient treatment is safe, effective, and preferred by low-risk patients. The researchers found that outpatient management is associated with substantial improvement in symptoms, and resulted in nearly universal return to work and usual activities within 30 days of being first seen by a physician.

17. III. Timely and Appropriate Antibiotic Therapy Timely and appropriate antibiotic therapy produces better outcomes. The early administration of antibiotic therapy (within 8 hours of hospital arrival) is associated with improved survival.

18. IV. Determining Medical Stability Before Discharge Can Reduce Mortality • It’s recommended before discharge to assess the five basic vital signs —temperature, heart rate, blood pressure, respiratory rate, and oxygen levels in the blood—as well as to assess the patient's mental status and ability to eat and drink. • Patients who are medically unstable—having problems with at least one of the seven factors—had greater chance of readmission or death and higher chance of not returning to their usual activities within 30 days. • Hospital guidelines should build in a safety check to measure clinical stability prior to discharge to ensure that patients are not discharged too soon.

19. Governmental program In the beginning of 2006 the Officials announced about cardinal changes in health care reform: 100 new hospitals in Georgia. The main idea of the program is to sold almost all hospitals (only 5 remains in the state property) to private companies and than they should build and equipped new hospitals in all over the country.

20. Governmental program The whole duration of the Program is 2-3 years and as of today more then 20 hospitals has been sold and building of new hospitals has been started.

21. The GRA Initiative The GRA had negotiation with one of the participants of the State program and it had been decided to create the Respiratory Medicine Centre in new hospital, that will include all aspects of RM. The medical devices and equipment will be brand new and the only thing we need is to train our staff.