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9th Prague International Health Summit: Role of Hospitals in the 21st Century

May 17–18, 2018

Implementing clinical protocols in a teaching hospital - case study

MUDr. Ing. Daniel Hodyc, Ph.D.

Advance Healthcare Management Institute

CZECH REPUBLIC

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Default arrangement

Clinic

Technology

Supplier

Hospital

Management

9th Prague International Health Summit: Role of Hospitals in the 21st Century

Technology

Supplier

Tries to prove that optimization of patient‘s

hemodynamic parameters during and

immediately after a surgery is beneficial both

clinically and economically

Clinic

Hospital

Management

3

9th Prague International Health Summit: Role of Hospitals in the 21st Century

Hospital

Management

Tries to improve patient care –

implement ERAS (Enhanced

Recovery After Surgery) protocol

into practice

Technology

Supplier

Department of

Anaesthesiology and ICM,

and Surgery clinic, 2nd

Faculty of Medicine, Charles

University in Prague and

Motol Teaching Hospital

Clinic

4

9th Prague International Health Summit: Role of Hospitals in the 21st Century

Hospital

Management

Technology

Supplier

Clinic

Tries to shorten excessive length

of stay and limit undesirable

variability of care

5

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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% of cases according to days of hospitalization

COLORECTAL SURGERY

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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% of cases according to days of IC

COLORECTAL SURGERY

9th Prague International Health Summit: Role of Hospitals in the 21st Century

Technology

Supplier

Clinic

Hospital

Management

We will implement

clinical protocols

8

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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ERAS protocol in Motol TH

Surgery clinic, 2nd Faculty of Medicine,

Charles University in Prague and Motol

University Hospital

COLORECTAL RESECTIONS

This clinical protocol is designated for patients undergoing elective colorectal resections in extent from ileocaecal

resection to rectal extirpation of any indication (C18,19,20,K573;D12;other).

This clinical protocol is not designated for acute condition patients and patients in need of a non-standard

preparation.

PATIENT’S ID PATIENT INVOLVED IN

CLINICAL PROTOCOL

FROM:

CLINICAL PROTOCOL

TERMINATED:

HOURS:

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Protocol example and its completion

Deviation + reason

Deviation + reason

Tick „X“ at

YES / NO / N/A YES – task was done

NO – task was not done – deviation from pathway

N/A – task is not to be done – not indicated

Day 0 – day of the surgery, preoperational stage Date:

Day 0 – day of the operation, preoperational stage

Medical procedure

Nursing procedure

Signature:

Signature

Medic

ati

on

Patient is able to undergo the operation

Prescription of ATB perioperative profylactic – protected koagulum

30-60 minutes before the operation

PNC intolerance:

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Criteria for transfer from ICU

Criteria for patient‘s discharge:

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

Patient without clinical signs of deep vein thrombosis

Patient without surgical site infec.

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Protocol

draft

Team

creation

How is a clinical protocol put into practice in a hospital

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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ERAS protocol implementation team at Motol Teaching Hospital

• Guarantors• Head of KARIM, doc. MUDr. Tomáš Vymazal, Ph.D., MHA

• Head of Surgical Clinic, prof. MUDr. Jiří Hoch, CSc

• Surgeon• MUDr. Petr Kocián, Ph.D.

• Anaesthetist• MUDr. Petr Přikryl, Ph.D.

• Nurses

• External coordinator

• Implementation support, methodology of analysis and results evaluation

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Protocol

draft

Team

creation

Comments

on protocol

New version

of protocol

Determination

of evaluation

parameters

Protocol

implementation

Evaluation of

results and

deviations

How is a clinical protocol put into practice in a hospital

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Evolution of protocol adherence in time

Total no. of cases ERAS ≥80%

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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97%

11%

37%

24%

50%

36%

66% 68%

16%

57%52%

93%

0%

20%

40%

60%

80%

100%

120%

Parenterální výživa Tolerance dietnízátěže (plná dieta do

4. POD)

Absence opiodů Mobilizace 1. POD

podíl p

řípadů

nonERAS ERAS<80 % ERAS>=80 %

Evaluation of clinical parameters –Perioperative Care

Significant difference

ERAS ≥ 80%

% o

f case

s

Parenteral

nutritionOpioids absenceDiet tolerance (full

diet to 4. POD)

Mobilization 1. POD

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Postoperative hospitalization

The length of stay was shortened without increase in re-hospitalizations

frequency (< 5 %)

5,2 5,3 3,8

7,5 6,1

5,7

0

2

4

6

8

10

12

14

nonERAS ERAS<80% ERAS≥80%

počet

dní hosp

italizace

Pooperačníhospitalizace naSTD

Pooperačníhospitalizace naJIP

1,8 difference in Standard

1,4 difference in ICU

Postoperative

hospitalization

at ICU

Postoperative

hospitalization

at standard

ward

No.

of

hosp

italizati

on d

ays

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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ERAS ≥80%nonERAS ERAS<80%

Most common ICU hospitalization length: 2 and 3 days

Days of postoperative ICUN

o.

of

case

s

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Costs comparison: Shortening of hospitalization length

Befo

re E

RAS

ERAS

(hig

her

adhere

nce >

80%

)

TRANSFER FROM ICUOPERATION (resection)

ICU -1,4 days STANDARD -1,8 days

ICU: 5,2 days STANDARD: 7,5

ICU: 3,8 days STANDARD: 5,7

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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STANDARD

STANDARD

Shortening of hospitalization length: effect on costs and profits

ICU

ICU

ICU

- 1,4 days

STANDARD

- 1,8 days

total

- 3,2 days

COSTS

EFFECT

PROFITS

Lower personnel costs

Rooms/beds reduction

Reduction of

variable costs –

„hotel“ services –

food, cleaning, bed

linen

Potentially higher

casemix when

utilizing the free

capacity

BED SAVINGS

No. of operations 200 450

ICU savings* 0,6 1,4

Standard ward savings* 0,8 1,8

* at 80% used capacity

Befo

re E

RAS

ERAS

(adhere

nce >

80%)

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Costs comparison: costs items with significant change

ICU STANDARD

ATB

LAB

NUTRITION

ERAS ≥ 80%

Difference of 2 150

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Costs comparison: costs items with significant change

ICU STANDARD

NUTRITIONATB

LAB

DIFFERENCW NON ERAS VS. ERAS>80: *** P < 0,1%

ERAS ≥ 80%

Difference of 600

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Costs comparison: costs items with significant change

ICU STANDARD

NUTRITIONATB

LAB

Difference of

185

9th Prague International Health Summit: Role of Hospitals in the 21st Century

24COSTS

Costs – original state

ICU

STANDARD

ATB

LABNUTRITION

9th Prague International Health Summit: Role of Hospitals in the 21st Century

25COSTS

Costs after implementation of some ERAS measures – improved patient care

ICU

STANDARD

ATB LABNUTRI

TION

HEMO-

DYNAMIC

MONITORING

PREVENTION

OF

HYPOTHERMIA

NUTRITIONAL

PREPARATION

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Costs after implementation of clinicalprotocol and all ERAS measures

ICU

STANDARD ATB

LABNUTRI

TION

HEMO-

DYNAMIC

MONITORING

PREVENTION

OF

HYPOTHERMIA

NUTRITIONAL

PREPARATION

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Conclusion

• After the implementation of ERAS Protocol:• The lab and nutrition use decreased

• Both ICU and Standard hospitalization length was shortened

• Potential impact on hospital economy:+ Higher profit – potential of free capacity utilization

+ Lower costs – personnel, beds, hotel services, opioids before operation

– Higher costs – hemodynamic monitoring LiDCO, warming up of patient and temperature measurement, preoperative nutritive preparation

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Technology

Supplier

Tries to prove that optimization of patient‘s

hemodynamic parameters during and

immediately after an operation is beneficial

both clinically and economically

Clinic

Hospital

Management

ERAS clinical protocol implementation –fulfilled expectations?

✔

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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ERAS clinical protocol implementation –fulfilled expectations?

Clinic

✔

Hospital

Management

Tries to improve patient care –

implement ERAS (Enhanced

Recovery After Surgery) protocol

into practice

Technology

Supplier

Department of

Anaesthesiology and ICM,

and Surgery clinic, 2nd

Faculty of Medicine, Charles

University in Prague and

Motol Teaching Hospital

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Hospital

Management

Tries to shorten excessive length

of hospitalization and limit

undesirable variability of care

ERAS clinical protocol implementation –fulfilled expectations?

✔

Clinic

Technology

Supplier

9th Prague International Health Summit: Role of Hospitals in the 21st Century

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Hospital

Management

Technology

Supplier

Clinical Protocol

Clinic

✔ ✔

✔

Standardization of care with the use of clinical protocols is a way how to connect interests of Hospital management, clinics, and suppliers