Zdravstveno obrazovanje u bolničkom sustavu
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1 Zdravstveno obrazovanje u bolničkom sustavu (kardiologija) Prof. dr. Davor Miličić Klinika za bolesti srca i krvnih žila KBC Zagreb i Medicinski fakultet Sveučilišta u Zagrebu
2 Bolnice nisu samo izvršitelji zdravstvenih usluga... Trajna višesmjerna edukacija! Liječnici subspecijalisti, specijalisti, specijalizanti, stažisti, sekundarci.. stipendisti Sestre VMS, MS... Bolničari Studenti dodiplomski i poslijediplomski Bolesnici poliklinički i ležeći Administrativno osoblje Pomoćno osoblje
3 Važnost srčanožilnih bolesti... Number of deaths (thousands) Heart disease and stroke No. of deaths (left axis) % of all deaths (right axis) Cancer Accidents Chronic lower resp. disease Male Female Diabetes % All deaths (male + female)
4 Od ateroskleroze do akutne ishemije UAP MI ACS Ischemic CVI/TIA Critical limb ischemia CV death Atherosclerosis Aherothrombosis Stabile angina pectoris Intermittent claudication Adapted from Stary HC et al. Circulation. 1995; 92: , and Fuster V et al. Vasc Med. 1998; 3:
5 Srčanožilne bolesti su sprječive npr. IM je može se predvidjeti u 90% slučajeva na temelju nekolicine klasičnih rizičnih čimbenika (INTERHEART) Primarna prevencija aterotrombotskih incidenata može bitno promijeniti sveopću sliku pobola i smrtnosti nacije Sekundarna prevencija infarkta srca (i mozga) ključ je uspjeha bolničkoga liječenja Cilj s.p: - smanjiti reinfarkt (re-cvi); invalidnost i umiranje - održati tj. povećati funkcijsku i radnu sposobnost - poboljšati kakvoću života
6 Liječenje je dvosmjeran proces! Bolesnike treba upoznati s problemom (pitanje elementarne etike i pitanje suradljivosti) Uspješnost liječenja izravno ovisi o informiranosti bolesnika i više je od puke farmakoterapije ( lifestyle changes! ) Edukacija bolesnika u bolnicama: poliklinika i stacionar
7 Mogućnost primarne i sekundarne prevencije KVB tj. edukacije bolesnika u bolnicama Poliklinički pogoni: Specijalističke ambulante za hipertenziju Ambulante i/ili dnevna bolnica za zatajivanje srca Aritmološke ambulante Opće kardiološke ambulante Klubovi bolesnika Stacionar
8 Arterijska hipertenzija
9 Arterijska hipertenzija (prevalencija u RH: cca 40%, EH-UH) Temeljem više e od 50 g. epidemioloških istraživanja, ivanja, hipertenzija je potvrđena kao izrazit čimbenik rizika srčano anožilnih bolesti, uključuju ujući i koronarnu bolest, CVI, perifernu arterijsku bolest, bubrežno zatajivanje i zatajivanje srca Kannel WB. Am J Hypertens 2000; 13:13S-10S 10S Hipertenzija je nazočna u polovice slučajeva zatajivanja srca i u trećine aterosklerotskih srčano anožilnih komplikacija Padwal R. BMJ 2001; 322:
10 Znaju li ovo naši hipertoničari ari? MacMahon et al, 1990 CVI koronarna bolest RR RR D Δ 10/5 mmhg = Rel.. rizik za 28%
11 Znaju li ovo naši hipertoničari? - nastavak - Bolest Koronarna bolest CVI Zatajivanje srca Relativni rizik (hipert pertenzivni enzivni vs. normotenzivni)) 2-3 x 7 x 2 3 x Periferna vaskularna bolest 2 3 x
12 Znaju li ovo naši hipertoničari? - nastavak - R i z i k prosječno sniženje u % Moždani udar 35 40% Infarkt miokarda 20 25% Zatajenje srca 50% JNC VII,JAMA, svibanj 2003.
13 Većina bolesnika ima složenu hipertenziju Složena hipertenzija 81% 19% 1 KV dodatni čimbenik rizika Bez dodatnog KV čimbenika rizika 1 dodatnih rizičnih čimbenika KBS, HLK Dijabetes, metabolički sindrom Bubrežna bolest Populacija s visokim rizikom
14 Osim dobi, spola i nasljeđa, svi ostali rizični čimbenici mogu se ukloniti
15 Edukacija bolesnika uključuje i upoznavanje s tzv. globalnim rizikom razvoja srčanožilne bolesti Hypertension SBP 165 mm Hg X1.9 X2.6 X4.5 X3.5 X2.3 Dyslipidemia TC 5.4 mmol/l (210 mg/dl) X1.3 Hypertension SBP 195 mm Hg X3.0 X5.3 X8.7 X5.2 X2.9 Dyslipidemia TC 6.1 mmol/l (235 mg/dl) X1.7 Glucose intolerance X1.8 Smoking X1.7 Risk shown above is compared with risk for a 40-year-old male nonsmoker with TC 4.7 mmol/l (185 mg/dl), SBP 120 mm Hg, and no glucose intolerance, ECG- LVH negative, whose probability of developing CVD is 15/1000 (1.5%) in 8 years Kannel WB. In: Genest J, et al, eds. Hypertension: Physiopathology and Treatment. New York, NY: McGraw Hill;1977:
16 Glavni čimbenici srčanožilnoga rizika Hipertenzija* Pušenje cigareta Pretilost* (BMI >30 kg/m 2 ) Tjelesna neaktivnost Dislipidemija* Diabetes mellitus* Mikroalbuminurija ili GFR <60 ml/min Dob (> 55 g. za muške, 65 g. za žene) Obiteljska anemneza preuranjene KVB (muški < 55 g. ili žene < 65 g.) *SASTAVNICE METABOLIČKOGA SINDROMA
17 METABOLIČKI SINDROM BOLEST NAŠEG DOBA Pretilost, HLP Hiperinzulinemija Inzulinska rezistencija Hipertenzija Prekomjeran unos kalorija Stres
18 Metabolički sindrom Inzulinska rezistencija, dislipidemija, pretilost & hipertenzija 15-25% pučanstva u industrijaliziranim zemljama 2-4 x rizik KV 5-9 x rizik nastanka NIDDM
19 Cjeloviti pristup čimbenicima rizika: zadaća za iduće desetljeće LDL-C Klasični čimbenici rizika KT Pušenje Novi čimbenici rizika Metabolički sindrom Inzulin Glu HDL-C Trbušna pretilost PAI-1 TNFα IL-6 TG T2DM SRČANOŽILNE BOLESTI
20 Granične vrijednosti opsega struka Novi kriteriji IDF: M Ž Europa >94 cm (37.0 in) >80 cm (31.5 in) Južna Azija >90 cm (35.4 in) >80 cm (31.5 in) Kina >90 cm (35.4 in) >80 cm (31.5 in) Japane >85 cm (33.5 in) >90 cm (35.4 in) Aktualni NCEP ATP-III kriteriji >102 cm (>40 in) za M, >88 cm (>35 in) za Ž NCEP 2002; International Diabetes Federation (2005)
21 Trbušna pretilost i povećan KV rizik The HOPE Study Adjusted relative risk Opseg struka (cm): 1.29 Tertile 1 Tertile 2 Tertile 3 M < > F < > KV smrtnost IM Opća smrtnost Prilagođeno s obzirom na BMI, dob, pušenje, spol, KV bolesti, DM, HDL-C, TC Dagenais et al 2005
22 Opasnost trbušne pretilosti krije se u unutartrbušnom adipozitetu Povišen kardiometabolički rizik Dislipidemija Hipertenzija Trbušna pretilost Intolerancija glukoze Inzulinska rezistencija Adapted from Eckel et al 2005 Unutartrbušni adipozitet
23 Koronarna bolest
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25 Patogeneza aterotromboze može li je shvatiti bolesnik? Plaque rupture Platelet adhesion Platelet activation and aggregation Partially occlusive arterial thrombosis and unstable angina or non-st-segment elevation MI Microembolization and non-st-segment elevation MI MI = myocardial infarction. Totally occlusive arterial thrombosis and ST-segment elevation MI Adapted from Davies. Circulation. 1990;82(supl II):II-38. White. Am J Cardiol. 1997;80(suppl 4A):2B.
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27 Edukacija bolesnika treba početi odmah kod primitka radi AKS Upoznavanje s prirodom bolesti radi pristajanja na (diferentnu) dijagnostiku i liječenje Upoznavanje s postupcima dijagnostike i liječenja Razvijanje svijesti o neophodnosti uklanjanja rizičnih čimbenika, što predstavlja dio liječenja
28 Edukacija uvjet suradljivosti bolesnika Objašnjavanje naravi i opsega bolesti kao i poduzete dg. i th. Procjena individualnog rizika (re-im, re-cvi i sl.) Analiza i plan uklanjanja čimbenika rizika kao conditio sine qua non! Objašnjavanje važnosti pridržavanja medikamentne terapije Prognostička važnost stručnoga praćenja bolesnika
29 Follow up i smrtnost nakon IM Melville M et al. BMJ 1999; 319: PROGNOZA JE LOŠIJA AKO IZOSTANE PRIMJERENI FOLLOW UP POSLIJE INFARKTA MIOKARDA 4-godišnji mortalitet nakon IM: -bez kontrola: 50% -uz kontrole: 24%
30 Mogućnosti za edukaciju bolesnika u bolnici U intenzivnoj skrbi: o bolesti, rizicima, liječenju, rehabilitaciji Na odjelu: plan dg. i liječenja, sekundarna prevencija i rehabilitacija Pojedinačni i grupni pristup Klubovi bolesnika Projekti za follow up
31 Primjer: PUTOVNICA ZA ŽIVOT
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33 Cilj programa Putovnica za život je edukacija i podizanje razine svijesti bolesnika Bolesnici Podizanje razine svijesti o bolesti i liječenju Postizanje veće suradljivosti bolesnika kod liječenja Kardiolozi i liječnici obiteljske medicine : suradnja bolnica i primarne zaštite radi optimalne sekundarne prevencije STRUKTURIRANO I KVALITETNO PRAĆENJE BOLESNIKA NAKON INFARKTA MIOKARDA
34 -SESTRE -STAŽISTI, SPECIJALIZANTI INTERNE/KARDIOLOG -FIZIOTERAPEUTI -PSIHOLOZI -PSIHIJATRI -DIJETETIČARI -STUDENTI MEDICINE Intervencijski centar Bolesnik Kardiolozi / Obiteljska medicina nakon PCI Trajna edukacija Seminari za bolesnike Kardiolozi
35 Cilj: Upoznati bolesnike s njima u trenutku kad su najviše zainteresirani tj. u klinici Potaknuti promjene stila i načina života (vježbanje, prehrana ) Pružiti mogućnost trajne edukacije bolesnika i kontakta s liječnikom nakon što izađu iz klinike (nakon IM odnosno intervencije) Putovnica za bolesnika Seminari za bolesnike DVD za bolesnika Edukativne brošure za bolesnike 3
36 Program Putovnica za život uključuje: 1. Seminare za liječnike 2. Seminare za bolesnike 3. Putovnicu za bolesnike (praćenje!) 4. Edukativne brošure za bolesnike 5. Edukativni video za bolesnike
37 1. Seminari za liječnike i sestre Upoznavanje liječnika/sestara s programom Kardiolozi u stacionarnoj i polikliničkoj službi Liječnici obiteljske medicine Načini izvedbe Lokalna predavanja ili okrugli stolovi Prikaz dostupnih materijala
38 Seminari za bolesnike Intervencijski centri: Novi bolesnici na programu za PCI (jednom tjedno?) Grupna edukacija za bolesnike (medicinska sestra) Edukativni video Edukativne brošure Putovnica Kardiolozi u ostalim bolnicama / Liječnici obiteljske medicine:
39 3. Putovnica za bolesnike Bolesnik dobiva Putovnicu nakon intervencije tj. prije odlaska iz bolnice Obavještava se o važnim aspektima liječenja Aktivno sudjeluje u liječenju (bilježi opaske, promjene i napredak liječenja) Potiče se cjeloviti pristup liječenje (dijeta, vježbe, redovito uzimanje terapije/ bolja suradljivost)
40 4. Brošura za bolesnike Bolesnik dobiva primjereni tekst o koronarnoj bolesti i načinima liječenja Brošura potiče na potrebu za promjenom životnog stila (prehrana, vježbanje, nepušenje, smanjenje stresa) Bolesnik se potiče na bolju suradljivost sa svojim liječnikom
41 5. Edukativni video za bolesnike Edukativni video se prikazuje bolesniku tijekom seminara u intervencijskom centru, prije intervencije (ili u bolnicama na kardiološkim odjelima i klinikama) Sadržaj videa prati sadržaj edukativne brošure i prikazuje bitne podatke o: Koronarnoj bolesti srca 3D animacija pokazuje razvoj plaka i objašnjava PCI Liječenju Promjenama životnog stila
42 Primjeri važnih edukativnih poruka
43 1. Koncept nestabilnoga plaka i kako ga spriječiti...
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47 2. vrijeme = miokard...svaka minuta kašnjenja s liječenjem u bolesnika s infarktom miokarda može biti Ustvari, rizik 1-godišnjeg mortaliteta povisuje se čak za 7,5% za svakih 30-min. zakašnjenja De Luca G et al, Circulation 2004; 109: miokard = život
48 ZAKLJUČAK Bolnica mora biti shvaćena ne samo kao mjesto dijagnostike i liječenja, nego i kao edukacijski centar za bolesnike Edukacija bolesnika treba biti obveza i sastavni dio rutinskoga posla liječnika i sestre Bolesnik postaje su-kreator u postupku dijagnostike i liječenja Obrazovanje bolesnika: ključ uspjeha sekundarne prevencije i liječenja u kardiologiji
49 Nonscholae, sedvitae discimus!
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