Considerazioni sul sistema di emergenza territoriale 118 a 25 anni dalla sua istituzione

Riferimenti normativi

  • DPR 27 marzo 1992, “Livelli di assistenza in emergenza urgenza”
  • DM 15 maggio 1992 “Classificazione interventi emergenza”
  • Atto di intesa tra Stato e regioni di approvazione delle linee guida sul sistema di emergenza sanitaria in applicazione del DPR 27 marzo 1992 17 maggio 1996 “Linee di guida n. 1/1996”
  • Legge Costituzionale 3/2001- Riforma del Titolo V
  • DPCM 29 novembre 2001 “Definizione dei livelli essenziali di assistenza”
  • 3 febbraio 2005. Documento della Conferenza Permanente per i rapporti tra lo Stato, le Regioni e le Province autonome di Trento e Bolzano “Linee guida per l’organizzazione dei servizi di soccorso sanitario con elicottero”
  • DMS 17 dicembre 2008 e ss.mm.ii. “Istituzione del flusso informativo per il monitoraggio delle prestazioni erogate nell’ambito dell’assistenza sanitaria in emergenza-urgenza”
  • Trimestrale Agenzia Nazionale Servizi sanitari regionali. Anno X, n. 27. 2011
  • 7 febbraio 2013. Documento della Conferenza Permanente per i rapporti tra lo Stato, le Regioni e le Province autonome di Trento e Bolzano “Linee di indirizzo per la riorganizzazione del sistema di emergenza urgenza in rapporto alla continuità assistenziale”
  • 11 aprile 2013. Documento della Conferenza Permanente per i rapporti tra lo Stato, le Regioni e le Province autonome di Trento e Bolzano “Accordo per l’organizzazione e l’assistenza sanitaria negli eventi e nelle manifestazioni programmate e nelle esercitazioni di emergenza territoriale”
  • 5 agosto2014. Documento della Conferenza Permanente per i rapporti tra lo Stato, le Regioni e le Province autonome di Trento e Bolzano “Linee Guida in materia di gestione degli interventi di emergenza sanitaria nelle aree e sulle linee ferroviarie”
  • Presentazione Gruppo di Lavoro Ministero Salute 15 ottobre 2014 “Numero Europeo armonizzato a valenza sociale 116117”
  • 25 marzo 2015. Documento della Conferenza Permanente per i rapporti tra lo Stato, le Regioni e le Province autonome di Trento e Bolzano “Coordinamento dei trasporti connessi alle attività trapiantologiche”
  • DM 2 aprile 2015, n. 70 “Regolamento recante definizione degli standard qualitativi, strutturali, tecnologici e quantitativi relativi all’assistenza ospedaliera”
  • Direttiva Presidenza del Consiglio dei Ministri. Dipartimento della Protezione Civile 22 giugno 2015 “Direttiva inerente “Centrale Remota Operazioni Soccorso sanitario” per il coordinamento dei soccorsi sanitari urgenti in caso di catastrofe nazionale e i “Referenti Sanitari Regionali per le grandi emergenze”
  • Legge 13 luglio 2015, n. 107. “La Buona Scuola”
  • 30 luglio 2015. Documento della Conferenza Permanente per i rapporti tra lo Stato, le Regioni e le Province autonome di Trento e Bolzano “Riconoscimento dei soggetti abilitati all’erogazione dei corsi di formazione finalizzati al rilascio dell’autorizzazione all’impiego dei defibrillatori semiautomatici”
  • DPCM 12 gennaio 2017 “Definizione ed aggiornamento dei livelli essenziali di assistenza di cui all’art. 1, comma 7, del decreto legislativo 30 dicembre 1992, n. 502”

Introduzione

Nel 2017 è caduto il 25° anno dall’istituzione nel nostro Paese del Sistema di Emergenza Territoriale 118 (SET118). Sembra opportuno ed appropriato ripercorrere ora il percorso e l’evoluzione del Sistema e considerarne i futuri sviluppi.

In epoca ante 118, in caso di emergenza sanitaria preospedaliera, il salvataggio dei Pazienti ed il relativo trasporto verso il più vicino ospedale veniva assicurato per lo più da Associazioni di volontariato e dalla CRI, strettamente legate al contesto del tessuto sociale territoriale, quando non da privati. Nella seconda metà degli anni ’80 cominciarono anche ad avere sviluppo in Italia servizi di elisoccorso aventi inizialmente come target iniziale per lo più il trasporto interospedaliero in emergenza urgenza.

L’attuale sistema di emergenza territoriale 118 prende origine e si sviluppa a partire dal 1992 con l’emanazione del DPR 27 marzo 1992 e con l’Atto di intesa tra Stato e Regioni del 17 maggio 1996 di approvazione delle linee guida sul sistema di emergenza sanitaria in applicazione del DPR 27 marzo 1992 “Linee di guida n. 1/1996”.

Il Decreto istituiva, all’art. 1, il livello assistenziale di emergenza sanitaria e ne organizzava, all’art. 2, le attività in un Sistema di allarme sanitario ed in un Sistema di accettazione e di emergenza sanitaria. Il primo Sistema era assicurato dalla Centrale Operativa, cui faceva riferimento il numero unico telefonico nazionale “118”, con compiti di ricezione delle chiamate di soccorso e coordinamento di tutti gli interventi nell’ambito territoriale di riferimento. Il secondo Sistema continuava ad essere assicurato dai Servizi ospedalieri di Pronto Soccorso dei Dipartimenti di emergenza. Il Servizio Sanitario Nazionale (SSN) allargava così la proprie garanzie e competenze al trasporto sanitario preospedaliero di emergenza urgenza.

Le Linee guida del 17 maggio 1996 implementavano il livello assistenziale di emergenza sanitaria definendo con maggiore definizione le attività del Sistema di Allarme Sanitario comprensive della valutazione del grado di complessità dell’intervento da attivare, dell’attivazione e del coordinamento degli interventi sanitari in emergenza urgenza nell’ambito territoriale di riferimento ed integrando una terza componente, il Sistema territoriale di soccorso, comprensivo di ambulanze di soccorso di base e di trasporto, ambulanze di soccorso avanzato, automezzi di soccorso avanzato, centri mobili di rianimazione ed eliambulanze, integrative delle altre forme di soccorso.

Sistemi di Emergenza Territoriale 118 (SET118) venivano progressivamente istituiti nelle diverse regioni fino al completamento della rete su tutto il territorio nazionale, entro il successivo decennio, con l’implementazione del SET118 nella Regione Puglia.

L’evoluzione del sistema

Nel corso dell’anno 2001, con la promulgazione della Legge Costituzionale 3/2001- Riforma del Titolo V, veniva introdotta una rilevante modifica nel panorama sanitario nazionale. L’ambito sanitario, fino ad allora di esclusiva competenza del Ministero della Salute, perlomeno dal punto di vista legislativo, diveniva materia concorrente tra Stato e Regioni/Province autonome. La nuova legge ampliava l’autonomia legiferativa delle Regioni portando, di fatto, ad una “regionalizzazione” della Sanità.

Con l’obiettivo di rendere uniforme il funzionamento della Sanità nelle diverse regioni italiane, il 29 novembre 2001 la Presidenza del Consiglio dei Ministri, con proprio decreto, introduceva il concetto dei Livelli Essenziali di Assistenza (LEA) articolandoli su tre macroaree, l’Assistenza sanitaria collettiva in ambiente di vita e di lavoro, l’Assistenza distrettuale e l’Assistenza ospedaliera. L’attività di emergenza sanitaria territoriale veniva compresa all’interno del livello di Assistenza distrettuale.

Successive norme e decreti, a livello nazionale, hanno implementato le attribuzioni e le competenze dei SET118 all’interno delle Regioni.

Nel 2005 l’incremento dei servizi e delle basi di elisoccorso nelle Regioni portava all’esigenza di una definizione e regolamentazione dell’attività degli stessi e, quindi, all’emanazione di Linee guida da parte della Conferenza Permanente per i rapporti tra lo Stato, le Regioni e le Province autonome di Trento e Bolzano.

In considerazione del continuo aumento delle attività dei SET118, a più di 15 anni dal DPR 1992, il Ministero della Salute ravvisava la necessità di censire il numero, la tipologia, le caratteristiche, le modalità di intervento e gli esiti degli interventi gestiti dal SET118 e dalle unità di Pronto Soccorso degli ospedali, ed istituiva con proprio Decreto del 23 dicembre 2008 uno specifico flusso informativo per effettuare con modalità uniformi su tutto il territorio nazionale il monitoraggio delle prestazioni erogate nell’ambito dell’assistenza sanitaria in emergenza-urgenza.

Specifico riconoscimento veniva dato al SET118 anche all’interno dei percorsi formativi delle classi della scuola primaria e secondaria nell’ambito degli interventi di base nel soccorso sanitario con Legge n. 107 del 13 luglio 2015.

Il 2 aprile 2015, con il D.Lgs. n. 70, il Ministero della Salute, di concerto con il Ministro dell’Economia e della Finanze, definiva gli standard qualitativi, strutturali, tecnologici e quantitativi relativi all’assistenza ospedaliera. Al capitolo 9.1 di tale decreto, Rete dell’emergenza urgenza, venivano definite le attività delle Centrali Operative 118 e della rete territoriale di soccorso considerando i relativi bacini di utenza per numero di abitanti, superficie e numero di prestazioni.

Il 24 giugno 2016, con specifica Direttiva e su proposta del Capo del Dipartimento della Protezione Civile, la Presidenza del Consiglio dei Ministri regolamentava l’individuazione all’interno dei SET 118 della Centrale remota operazioni soccorso sanitario (CROSS) per il coordinamento dei soccorsi sanitari urgenti definendo e precisando così l’attività del Sistema 118 nella gestione di eventi emergenziali particolarmente all’interno delle prime 72 ore.

Il 12 gennaio 2017 la Presidenza del Consiglio dei Ministri aggiornava il DPCM del 29 novembre 2001 assegnando alle Centrali 118, nell’arco delle 24 ore, le attività di emergenza sanitaria preospedaliera, in modo integrato con le attività di emergenza intraospedaliera e sanitaria di base e di Continuità assistenziale, i trasporti sanitari assistiti e non assistiti, le attività assistenziali ed organizzative in occasione di maxiemergenze anche NBCR ed in occasione di eventi e manifestazioni programmate.

Dal 2013 al 2015 infine, con successivi documenti, la Conferenza Permanente per i rapporti tra lo Stato, le Regioni e le Province autonome di Trento e Bolzano riconosceva la competenza del SET118 in relazione ai rapporti con la Continuità Assistenziale nell’ambito dell’istituzione  delle Centrali a numero unico di chiamata 116117 per le cure mediche non urgenti, al coordinamento delle attività di soccorso in occasione di eventi, manifestazioni programmate ed esercitazioni di emergenza territoriale, alla gestione degli interventi di emergenza sanitaria nelle aree e nelle linee ferroviarie, al coordinamento dei trasporti connessi alle attività trapiantologiche, al riconoscimento dei soggetti abilitati all’erogazione dei corsi di formazione finalizzati al rilascio dell’autorizzazione all’impiego dei defibrillatori semiautomatici.

Oltre alle funzioni previste nel DPR 27 marzo 1992 e nelle successive Linee guida n. 1/1996 di valutazione del grado di complessità dell’intervento da attivare e di attivazione e coordinamento degli interventi sanitari in emergenza urgenza nell’ambito territoriale di riferimento l’attività del SET118 si estende quindi oggi anche all’interno dei percorsi formativi delle classi della scuola primaria e secondaria nell’ambito degli interventi di base nel soccorso sanitario, al coordinamento delle attività in corso di maxiemergenze, di eventi, manifestazioni programmate ed esercitazioni di emergenza territoriale, ai trasporti di emergenza intraospedaliera, ai trasporti ordinari, ai rapporti con la Continuità Assistenziale nell’ambito dell’istituzione delle Centrali a numero unico di chiamata 116117 per le cure mediche non urgenti, al coordinamento delle attività di soccorso in occasione degli interventi di emergenza sanitaria nelle aree e nelle linee ferroviarie, al coordinamento dei trasporti connessi alle attività trapiantologiche, al riconoscimento dei soggetti abilitati all’erogazione dei corsi di formazione finalizzati al rilascio dell’autorizzazione all’impiego dei defibrillatori semiautomatici. La progressiva estensione al periodo notturno delle operazioni di elisoccorso in un numero sempre maggiore di basi, grazie anche all’evoluzione tecnologica delle strumentazioni di bordo degli aeromobili, aggiunge problematiche all’attività dei SET118.

I ridisegno infine della rete e delle funzioni hub e spoke dei presidi ospedalieri per acuti ai sensi del Decreto 70/2015 e l’ulteriore definizione quindi della rete dei trasporti di emergenza all’interno dei Percorsi Diagnostico Terapeutici, in particolare per le patologie tempo dipendenti, costituisce infine un ulteriore elemento di complessità per l’attività dei SET118.

Considerazioni sullo stato dell’arte

Attuale stato dell’arte e future possibilità di sviluppo vanno lette alla luce di quelli che costituiscono gli obiettivi del servizio sanitario in emergenza urgenza in un concetto di “governance regionale di sistema”. Tali obiettivi, declinati secondo criteri di efficienza, efficacia, appropriatezza, equità di accesso, sicurezza, soddisfazione degli utenti tanto primari che secondari, rispetto delle disponibilità economiche, sono costituiti da:

  1. Continuità delle cure dalla sede di insorgenza dell’evento, alle strutture di accettazione ed ai DEA di riferimento secondo Percorsi Diagnostici Terapeutici Assistenziali (PDTA) predefiniti all’interno di ogni SET118.
  2. Gestione omogenea ed uniforme delle attività sanitarie in emergenza urgenza tra i diversi SET118 regionali a garanzia dell’equità di accesso al Sistema ospedaliero delle emergenze da parte di tutta la popolazione con adozione di protocolli comuni di valutazione, codifica, gestione delle missioni di emergenza sanitaria.
  3. Garanzia, all’interno di ogni regione, di percorsi formativi omogenei e strutturati a tutte le componenti delle Centrali operative 118 e dei relativi Sistemi Territoriali di Soccorso ivi compreso il Servizio di elisoccorso.
  4. Realizzazione di percorsi di integrazione della componente territoriale con quella ospedaliera delle strutture di accettazione dei DEA. Le caratteristiche dell’intervento sanitario a carattere di emergenza urgenza, al di là delle differenze tra setting pre ed ospedaliero, sono assolutamente sovrapponibili e complementari tra loro e, del resto, la Scuola di specializzazione di Medicina d’Emergenza-Urgenza prevede un’omogeneità di percorso formativo sia per il personale dell’emergenza pre che per quello dell’emergenza ospedaliera.
  5. Adozione di idonee politiche della qualità per un miglioramento continuo del Sistema.

Il raggiungimento degli obiettivi si basa su uno stretto legame ed un comune assetto organizzativo, all’interno del SET118, tra Sistema di allarme sanitario e Sistema territoriale di soccorso, sulla pianificazione degli sviluppi del Sistema per obiettivi prefissati, su un adeguato finanziamento in relazione alla attività pianificate, sulla adozione di adeguate politiche della qualità.

Di particolare rilevanza appare in tali contesti il primo punto cioè la realizzazione all’interno del SET118 di un unico assetto organizzativo, tra Sistema di allarme sanitario e Sistema territoriale di soccorso essendo il secondo il principale strumento di validazione delle attività, svolte dal primo, di ricezione, valutazione della chiamata e del grado di complessità dell’intervento da attivare, coordinamento degli interventi sanitari in emergenza urgenza nell’ambito territoriale di riferimento così come il Sistema di allarme sanitario deve essere idealmente testimone e garante della funzionalità del secondo in relazione alla aderenza degli equipaggi di soccorso alle linee guida terapeutiche regionali ed alla corretta allocazione dei Pazienti nelle sedi ospedaliere appropriate in osservanza dei PDTA regionali. Tale sembra essere peraltro la direzione indicata dal DM 70/2015 nella misura in cui, all’interno del capitolo 9 (Rete dell’emergenza urgenza), considera le Centrali Operative 118 e la Rete territoriale di soccorso (comprensiva sia dei sistemi di trasporto su gomma che dei sistemi di elisoccorso) unitamente all’interno del paragrafo 9.1 trattando a parte, nel successivo paragrafo 9.2, la Rete ospedaliera dell’emergenza.

La straordinaria complessità raggiunta dal Sistema e la valenza degli obiettivi da perseguire hanno portato all’individuazione di diversi assetti organizzativi nei diversi contesti regionali. Progettazione, organizzazione, valutazione delle attività svolte, implementazione di risorse, finanziamento dei SET118 e relativi centri di responsabilità e centri di costo sono stati quindi riferiti di volta in volta, in diverse Regioni, ad Aziende sanitarie regionali con caratteristiche “strutturali” piuttosto che “funzionali” o a Dipartimenti sanitari interaziendali a valenza regionale piuttosto che di macroarea o di area vasta, secondo la Vision dei diversi organi legislativi regionali, riconoscendo alle Centrali 118 il ruolo di Unità Operativa Complessa (UOC). Altre Regioni hanno assunto una visione più parcellizzata del problema considerando le Centrali Operative 118 nel ruolo di Strutture Semplici dipartimentali quando non strutture Semplici di UOC ospedaliere.

Tali asimmetrie oltre che non funzionali all’erogazione, sul territorio, di un livello assistenziale fondamentale, come quello relativo all’emergenza urgenza, in maniera il più possibile uniforme su tutto il territorio nazionale appaiono anche disfunzionali al raggiungimento degli obiettivi citati.

In relazione ai punti precedenti considerazioni e riflessioni vanno avanzate, in particolare, su tre punti:

  1. Dimensionamento dei SET118 considerati unitariamente nelle funzioni di Sistemi di allarme sanitario (Centrali 118) e territoriali di soccorso.
  2. Organizzazione e funzionalità della reti territoriali di soccorso in relazione all’interfaccia della loro operatività tanto con l’Assistenza Distrettuale che con l’Assistenza Ospedaliera.
  3. Modalità di finanziamento del SET118 all’interno dei Servizi Sanitari regionali (SSR).

 

Dimensionamento dei SET118

Il Decreto 70/15 prevede una revisione organizzativa che considera una Centrale Operativa 118 con un bacino di riferimento orientativamente non inferiore a 0,6 milioni ed oltre di abitanti o almeno una per Regione/Provincia autonoma. Lo stesso Decreto prevede la possibilità, per le stesse centrali, di assumere anche il coordinamento dei trasporti programmati. I documenti sopracitati della Conferenza Permanente per i rapporti tra lo Stato, le Regioni e le Province autonome di Trento e Bolzano assegnano al SET118 la competenza dei rapporti con la Continuità Assistenziale nell’ambito dell’istituzione delle Centrali a numero unico di chiamata 116117 per le cure mediche non urgenti, il coordinamento delle attività di soccorso in occasione di eventi, manifestazioni programmate ed esercitazioni di emergenza territoriale, nella gestione degli interventi di emergenza sanitaria nelle aree e nelle linee ferroviarie, in occasione dei trasporti connessi alle attività trapiantologiche nonché il riconoscimento dei soggetti abilitati all’erogazione dei corsi di formazione finalizzati al rilascio dell’autorizzazione all’impiego dei defibrillatori semiautomatici. Da ultimo, appare di fondamentale anche il coinvolgimento del SET118 nei percorsi formativi scolastici delle classi della scuola primaria e secondaria.

Alla luce di tali normative, fissato a non meno di 0,6 milioni ed oltre di abitanti il bacino minimo di utenza di un SET118, considerate tutte le funzioni assegnate, bacini di utenza superiori ad un massimo di 1,5 milioni di abitanti potrebbero essere disfunzionali al corretto espletamento di tutte le attività previste fatto salvo lo spacchettamento delle attività in altre centrali o subcentrali, con altro e diverso personale, con un incremento dei costi ed un peggioramento delle performance di sistema.

Organizzazione e funzionalità del personale delle Reti territoriali di soccorso

Le Reti territoriali di soccorso (RTS), intese come l’insieme del personale, delle attrezzature e dei mezzi delle postazioni territoriali, elisoccorso compreso, garantiscono il soccorso qualificato sul luogo in cui si verifica un’emergenza sanitaria nonché l’operatività nei Punti di Primo Intervento (PPI) residui individuati dal DM 70/15. Tali reti operano anche, in caso di trasporto del Paziente, il raccordo tra sede dell’evento ed Ospedali di destinazione con una doppia interfaccia tra Centrale 118, che attiva la missione, e strutture di Pronto Soccorso, che danno accoglienza al Paziente.

È compito di tale personale, insieme al personale della Centrale, l’armonizzazione dei diversi percorsi clinici ed assistenziali, l’ottimizzazione dell’uso delle risorse attraverso la diffusione delle buone pratiche cliniche, l’adozione di politiche destinate al miglioramento continuo della qualità degli interventi sanitari e dell’organizzazione ad essi sottesa, l’omogeneizzazione dell’assetto operativo ed organizzativo, il conseguimento di risultati adeguati in termini di efficienza, efficacia, appropriatezza con percorsi formativi e tecniche di intervento in gran parte assimilabili a quelle dell’emergenza ospedaliera.

In attesa della disponibilità di un adeguato numero di Medici Specialisti formati nelle Scuole di specializzazione di emergenza ed urgenza, attesa di una prevedibile e ragionevole durata non inferiore ottimisticamente ad almeno un decennio, opera attualmente nell’emergenza territoriale personale medico con diversi rapporti contrattuali tra convenzionamento e dipendenza ed a diversa dipendenza tra le Unità Operative dei DEA, tra Pronto Soccorso, Centrali Operative e Terapie intensive, con evidenti problematiche di uniformità di gestione delle attività a livello territoriale. Risulta spesso difficile identificare in tal senso una “catena delle responsabilità” ben definita in relazione anche all’individuazione e assegnazione di “obiettivi di performance” uniformi all’interno della rete Territoriale di Soccorso (RTS a personale con diverse afferenze contrattuali.

Nel breve periodo potrebbe essere migliorativo un percorso di passaggio alla dipendenza del personale convenzionato attualmente operante nel RTS (considerati livelli prefissati di anzianità di servizio) o, in alternativa, perlomeno, riconoscerne la possibilità di accedere a procedure di assunzione concorsuali pur in assenza di specializzazione (sempre considerati livelli prefissati di anzianità di servizio) così come sembra ragionevole percorrere diversi percorsi di acquisizione di nuovo personale rivolti, oltre naturalmente al personale in possesso della specializzazione di emergenza ed urgenza, anche a personale comunque in possesso di specializzazione al termine di specifici percorsi formativi, tanto nel campo dell’emergenza pre che in quella ospedaliera, normati a livello regionale.

Di grande attualità risulta anche la definizione a livello nazionale/regionale dei percorsi di autonomia del personale infermieristico in emergenza urgenza nel rispetto, naturalmente, dei ruoli, delle norme deontologiche e dei percorsi formativi delle professionalità coinvolte.

Modalità di finanziamento del SET118 all’interno dei Servizi Sanitari Regionali

Il Sistema di Emergenza Territoriale (SET) 118 opera, a ponte, tra assistenza distrettuale territoriale ed assistenza ospedaliera non insistendo peraltro in maniera esclusiva su nessuna delle due tipologie. Esso presenta precipue caratteristiche organizzative e funzionali, nonché particolare complessità e univoca specificità, sia per la tipologia di prestazioni, sia per i livelli di competenza e sia per le modalità operative, tali da renderlo distinto dalle aree sanitarie classiche ospedaliere e distrettuali. Come normato a partire dal DPCM 29 novembre 2001 “Definizione dei livelli essenziali di assistenza” e confermato dal DPCM 12 gennaio 2017 “Definizione ed aggiornamento dei livelli essenziali di assistenza”, il SET-118 è compreso all’interno dell’Assistenza distrettuale. In contrasto con tale appartenenza le Centrali Operative 118, fatte salve alcune esperienze regionali di Aziendalizzazione dell’emergenza, operano all’interno dei DEA ospedalieri. In tale situazione risulta estremamente difficoltoso procedere a percorsi di progettazione, pianificazione, organizzazione delle attività, valutazione dei risultati, finanziamento delle risorse, istituzione di adeguati centri di responsabilità e centri di costo finalizzati ad un funzionamento ottimale dei SET118 nella pienezza delle loro funzioni ed attribuzioni in ambito regionale. All’interno dei diversi contesti organizzativi dei SET118 andrà organizzato, di fatto e per gli stessi, un finanziamento distinto rispetto alle altre macrocomponenti sanitarie Distrettuale ed Ospedaliera.

Ulteriori ed attuali prospettive di sviluppo ai sensi delle normative europee riguardano infine l’attività del SET118 nell’ambito della realizzazione delle Centrali Uniche di Risposta (CUR) al numero unico europeo delle emergenze 112 e delle Centrali per il coordinamento delle cure mediche non urgenti con numero unificato di chiamata 116117, Tali realizzazioni potranno anche portare contributi importanti nell’ambito della risoluzione di almeno alcune delle problematiche trattate ed infine, se resta fondamentale il raggiungimento di una uniformità di risposta all’emergenza sanitaria in ambito regionale, quanto potrà essere possibile l’estensione del progetto in un ambito nazionale con la realizzazione di un progetto SET118 Italia?

Riccardo Sestili

Past President SIS 118

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    its power understand what exactly Reiki does and what its effects are.
    If you are interested in the best way Reiki can help you, then please read
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    1. Increases our bodies’s ability to heal itself. Normally, the
    body carries a defense system which functions good provided that
    the Ki flow is just not interrupted. When the Ki is
    no longer capable of flow through your body, illnesses and diseases can be shown. Reiki
    stimulates the flow of positive energy, thus enabling our bodies to heal itself and fight the internal and
    external attacks more effectively.
    2. Cleans your body of all toxins. Because it acts on the system, it really is one
    of the few complete detox programs it’s possible to follow.
    In addition to that no involve refraining from food or other sort
    of activity. Yet, pessimism must be banned from your individual’s mind because they may have
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    3. Promotes health, positive thoughts and relaxation. The principles of Reiki rely on positive thinking,
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    By removing negative energy and promoting a sense peace,
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    illness or disease where the average person suffers.

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