TQIP对外科预防性抗生素使用之影响

1、品質改善成本效益TQIP對外科預防性抗生素使用之影響國泰綜合醫院 黃清水副院長2021/9/101Model of a National Health SystemHealth ResultManagementOrganizationEconomicsupportResourcesServices deliveryHealth Needs2021/9/102Limited Medical Resourcesvs.Optimal Healthcare Quality2021/9/103Low Cost vs High Effectiveness= Cost-effective(The relat

2、ionship between achieving certain objectives and consumption of resources， costs vs outcomes)2021/9/104Efficacy vs Effectiveness Efficacy is a measure of the extent to which objectives (result, cure) are achieved in real practice settings. Effectiveness concerns generalizability of results of treatm

3、ent.2021/9/105Healthcare Cost as % of GNP13.4% - 13.7%(5.4% Taiwan)2021/9/106US Healthcare Cost in $1.491 TrillionPredicted increase of 10% in 2000 2.2 Trillion by 20082021/9/107Cost-EffectivenessCLIENTPROVIDERPAYERSOCIETY2021/9/108Cost of Surgical OperationsExpendable suppliesInstrumentsEquipmentIm

4、plantsFacility CostEmployeesPre-op testing2021/9/109Expendable suppliesLaparotomy packageGown, gloves and towelsPrepEKG and oxygen finger padsAnesthesia gases and masksLocal anesthesia and antibiotics2021/9/1010Medical (Year 2000)Hospital 40%Professional 42%Pharmacy 18%(25% Taiwan)2021/9/1011Full Ti

5、me EmployeeReceptionistPreop nurseCirculating nurseSurgical techRecovery room nurseOR supervisorCOO facility- $22/hr for 9-9/5hrs for each case $209/hr. for every case2021/9/1012品質成本預防性成本：教育訓練, 資格認定, 指標建立, 治療共識評鑑成本：定期監測, 稽核,滿意度調查內部失敗成本： 執行前或執行中失敗之成本外部失敗成本：錯誤導致醫療糾紛與賠償2021/9/1013Effectiveness-Outcome

6、measurement病人方面：Audit of patient outcomes(併發症,死亡率,住院日,病假日,回復工作能力,生活品質,長期結果,再發率,存活率)第三付費者：健保支出2021/9/1014TQIP對外科預防性抗生素使用之影響抗生素費用是全院藥品費用支出之大宗合理使用抗生素可避免藥物副作用89年衛生署提出本院清淨手術抗生素之使用量偏高院內缺乏系統性收集外科預防性抗生素使用指標2021/9/1015設定目標合理化外科預防性抗生素之使用不影響外科病患感染率為前提下掌握使用時效降低抗生素使用量2021/9/1016方 法立意取樣：TQIP II b ：CABG、THR、TKH、AT

7、H、APP. 五種術式收案對象之預防性抗生素使用對象：醫療服務提供者方法：Cost / Effect iveness ratio2021/9/1017成本效益指標使用量 使用費用使用時間（過程）院內感染率（結果）平均住院天數（結果）Independent t-test2021/9/1018分科檢討改善修正工作流程，例:術前預防性抗生素改至手術室施打 (心臟外科優先，再推廣至他科)醫師準時上刀(配合醫品圈) ，訂出賞罰規則以婦產科為例參考文獻，依據數據，全力溝通原有CQI團隊共識主治醫師會議修正臨床路徑2021/9/1019資訊公開適時回饋醫品會議檢視每季趨勢比較世界、台灣、同等級醫院檢討異常值

8、，相關科部提出說明科主任會議:公開資訊、共同協商改進提供科部相關指標書面資料全院業務會議:加強共識2021/9/1020使用量的降低TKR、THR、CABG、APP、ATH各術式抗生素使用量與費用曲線圖各術式抗生素使用量年度比較各術式抗生素費用年度比較 t-test得到的p-value2021/9/1021改善情況TKR抗生素之使用季別加入TQIP使用支數金額2021/9/1022TKR抗生素使用量同期比較季別支 數/人次2021/9/1023TKR抗生素費用同期比較季別元/人次2021/9/102489Mean+SD90Mean+SD91Mean +SDp-valueQ134.27+ 13.

9、0627.37+12.510.61Q234.81+12.5631.54+14.670.34Q324.76+11.8628.29+11.070.65Q444.15+59.6420.82+10.300.13TKR抗生素使用量2021/9/102589Mean+SD90Mean+SD91Mean +SDp-valueQ14738.25+1897.362731.37+1192.040.39Q23522.42+1261.183144.23+1498.980.24Q32490.36+1228.742976.41+1146.790.80Q46358.30+8595.152154.23+1042.840.09

10、TKR抗生素費用2021/9/1026改善情況THR抗生素之使用季別加入TQIP使用支數金額2021/9/1027THR抗生素使用量同期比較季別支 數/人次2021/9/1028THR抗生素費用同期比較季別元/人次2021/9/102989Mean+SD90Mean+SD91Mean +SDp-valueQ134.27+13.0627.26+13.470.85 Q230.67+7.9927.70+15.800.30Q326.68+8.1929.82+11.810.08Q444.55+12.0732.82+35.920.10THR抗生素使用量2021/9/103089 Mean+SD90Mean

11、+SD91Mean +SDp-valueQ14738.25+1897.362751.70+1369.770.35Q23205.90+991.792809.52+1615.550.50Q32691.74+870.953091.06+1183.940.15Q49804.6+1808.384337.05+7752.430.08THR抗生素費用2021/9/1031改善情況CABG抗生素之使用季別加入TQIP使用支數金額2021/9/1032CABG抗生素使用量同期比較季別支 數/人次2021/9/1033CABG抗生素費用同期比較季別元/人次2021/9/103489Mean+SD90Mean+SD

12、91Mean +SDp-valueQ163.26+50.4245.58+14.290.11Q256.50+22.6848.83+21.510.63Q350.67+20.7839.31+20.120.62Q471.77+59.8658.50+28.120.31CABG抗生素使用量2021/9/1035899091p-valueMean+SDMean+SDMean +SDQ112402.98+16464.785318.92+2914.660.08Q28335.23+2908.485180.22+2111.060.08Q36072.93+32583964413.00+2517.470.42Q4148

13、91.34+26166.637665.00+4383.870.12CABG抗生素費用2021/9/1036改善情況APP抗生素之使用季別加入TQIP使用支數金額2021/9/1037APP抗生素使用量同期比較季別支 數/人次2021/9/1038APP抗生素費用同期比較季別元/人次2021/9/103989Mean+SD90Mean+SD91Mean +SDp-valueQ129.70+39.0621.82+13.140.00 Q224.83+16.9123.53+9.880.02 Q320.78+17.4021.78+8.830.00 Q430.04+20.0522.02+11.140.00

14、 APP抗生素使用量p.01 p.052021/9/1040899091p-valueMean+SDMean+SDMean +SDQ1Q2Q3Q44630.09+4354.193972.84+7783.552578.24+2263.222106.53+3039.062255.18+1286.892177.07+1419.53 2459.81+1115.65 2199.52+1015.130.000.000.000.00APP抗生素費用p.012021/9/1041改善情況ATH抗生素之使用季別加入TQIP使用支數金額2021/9/1042ATH抗生素使用量同期比較季別支 數/人次2021/9/

15、1043ATH抗生素費用同期比較季別元/人次2021/9/1044改善成效使用時間掌握使用時效劃刀前30分鐘內之預防性抗生素使用情況劃刀前2小時之預防性抗生素使用情況使用期限24小時TKR THRCABGAPPATH2021/9/1045百分比II-b: Surgical ProphylaxisRate-Knee Arthroplasty Surgical Prophylaxis Within 30 minutes Prior to Incision (2001q1)(8/18)(8/26)(13/31)(13/20)(13/25)2021/9/1046百分比II-b: Surgical Pr

16、ophylaxisRate-Hip Arthroplasty Surgical Prophylaxis Within 30 minutes Prior to Incision (2001q1)(5/15)(3/20)(7/26)(10/30)(6/26)2021/9/1047百分比II-b: Surgical ProphylaxisRate-CABG Surgical Prophylaxis Within 30 minutes Prior to Incision (2001q1)(5/22)(12/36)(3/15)(4/25)(7/28)2021/9/1048百分比II-b: Surgica

17、l ProphylaxisRate-Appendectomy Surgical Prophylaxis Within 30 minutes Prior to Incision (2001q1)(9/79)(5/104)(3/101)(6/70)(5/68)2021/9/1049百分比II-b: Surgical ProphylaxisRate-Abdominal Hysterectomy Surgical Prophylaxis Within 30 minutes Prior to Incision (2001q1)(33/57)(43/57)(50/68)(34/36)(34/43)2021

18、/9/1050百分比II-b: Surgical ProphylaxisRate-Knee Arthroplasty Surgical Prophylaxis Within 2 hours Prior to Incision(17/22)(17/18)(25/26)(27/31)(20/20)(24/25)2021/9/1051百分比II-b: Surgical ProphylaxisRate-Hip Arthroplasty Surgical Prophylaxis Within 2 hours Prior to Incision(18/22)(12/15)(19/20)(21/26)(30

19、/30)(22/26)2021/9/1052百分比II-b: Surgical ProphylaxisRate-CABG Surgical Prophylaxis Within 2 hours Prior to Incision(31/33)(21/22)(35/36)(15/15)(25/25)(28/28)2021/9/1053百分比II-b: Surgical ProphylaxisRate-Appendectomy Surgical Prophylaxis Within 2 hours Prior to Incision(80/87)(67/79)(92/104)(88/101)(61/68)(68/70)2021/9/1054百分比II-b: Surgical ProphylaxisRate-Abdominal Hysterectomy Surgical Prophylaxis Within 2 hours Prior to Incision(50/57)(73/74)(50/57)(67/68)(35/36)(43/45)2021/9/1055百分比II-b: Surgical ProphylaxisRate