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Outcomes REPORT 2016
Orthopedics
32
04 MESSAGE FROM THE PRESIDENT
06 INTRODUCTION
08 OVERVIEW – HOSPITAL ISRAELITA ALBERT EINSTEIN
10 OVERVIEW – EINSTEIN ORTHOPEDICS
12 LOCOMOTOR PROGRAM
16 SERVICE STRUCTURE AND VOLUME
34 CLINICAL STAFF
38 QUALITY AND CLINICAL OUTCOMES
72 PATIENT EXPERIENCE
76 EDUCATION AND SCIENTIFIC EVENTS
82 RESEARCH AND SCIENTIFIC PRODUCTION
88 SOCIAL RESPONSIBILITY
90 BRAND DISSEMINATION AND MANAGEMENT
92 STAFF & CONTACT INFORMATION
List of Contents
4
Message from the President
Defined as a strategic area for Einstein
for almost a decade, Orthopedics has
been reinforcing year after year its capacity
to incorporate practices and processes of
excellence that fuel quality of care and patient
safety. In addition, it has emphasized its vocation
to break with barriers and create new paradigms,
such as the Spine and Cranial Maxillofacial
programs, which are based on transparent,
qualified and ethical assessments that contribute
to prevent unnecessary surgeries. Similarly to
its clinical achievements, our Orthopedics has
also given attention to knowledge generation
and dissemination by adopting teaching
and research activities together with social
responsibility actions.
This report brings information and indicators
about all these dimensions. Internally, we use
these data as a management tool to guide our
improvement processes. However, we also think
they are of interest to people from outside the
organization. By transparently and broadly
sharing them, we provide to physicians, patients
and other stakeholders objective information
to guide their choices and decisions. Moreover,
by showing the path we have taken we want to
inspire other professionals and organizations to
follow along, disseminating these practices of
excellence throughout the country.
Counting on a highly qualified clinical staff,
specialized multidisciplinary teams to treat
orthopedic patients, advanced technological
resources, protocols and procedures constantly
reviewed and integrated with the remaining
areas of the organization, Einstein orthopedics
has been yielding increasingly positive results.
You can confirm that by checking the outcome
indicators, quality and safety data contained in
this report. At the same time, we have reduced
the average length of stay, which benefits
the patient, reduces costs and the risk of
complications, in addition to providing better
bed management by the organization.
Our Orthopedics area has also stood out in
research, by being entitled to funding for three
major projects and constantly increasing its
number of publications (25 in 2016). Concerning
teaching, resident physicians and graduate
students have completed their courses. The area
has also held events such as the 1o Simposio de
Coluna (1st Spine Symposium), which attracted
a significant number of participants interested in
learning about our protocols and other relevant
aspects of the Spine Program.
Concerning social responsibility, numbers mean
more than a thousand words: in 2016, there
were over 8,400 orthopedic visits at Hospital
Municipal Dr. Moyses Deutsch - M’Boi Mirim,
which amounts to 25% of the total volume of
outpatient visits in the year.
It all confirms that our Orthopedics Area is
permanently committed to building qualified
and sustainable care, aligned with the pillars
of Triple Aim Initiative, from the Institute
for Healthcare Improvement (IHI): improved
quality of care, lower costs and promotion of
population health.
The area of Orthopedics has been confirming its capacity to incorporate practices and processes of excellence; in addition, it has emphasized its vocation to break with barriers and create new paradigms, such as the Spine and Cranial Maxillofacial programs.
Sidney Klajner, MDPresident of Sociedade Beneficente Israelita Brasileira Albert Einstein
5
6
Introduction
2016 was a year of important breakthroughs for
the areas of Orthopedics and Rheumatology
at Einstein. The launch of innovative initiatives
at the Locomotor Program, continuous
improvement of our guidelines and evidence-
based protocols that ensure better care to
patients, the actions that provide smart use of
resources to optimize costs, and the investments
in new technologies are examples of the advances
that have consolidated Einstein as a reference in
orthopedics.
In our journey, we have been leading transforming
and inspiring initiatives. Seven years ago, we
successfully launched the Spine Program, a
second opinion program for patients who
have indication for surgical treatment of spine
conditions: the analyzed cases have shown that
almost half of the patients could benefit from
conservative treatment. Based on this very
successful model, we have launched the Cranial
Maxillofacial Program, offering a second opinion
for the treatment of orthognathic pathologies,
temporomandibular joint diseases and sleep
apnea, based on the multiprofessional assessment
of at least two surgeons from the specialty and
the best scientific evidence. Our results are quite
surprising: within one year of activities, we have
noticed that 90% of the patients who had surgical
indication and came to ask for a second opinion
could benefit from conservative treatment, which
is less aggressive and more affordable.
Constantly trying to bring together quality,
effectiveness and sustainability, we have also
promoted in 2016 the standardization of materials
used in spine, oral maxillofacial, arthroplasty and
arthroscopy procedures. In this process, we could
focus on the best available implants in the world,
reducing the number of suppliers. In other words,
standardization means efficient management of
materials and favors the patients, who can have
high-quality implants.
We have maintained our investment in
technology. The highlight in 2016 was the
acquisition of an endoscope used in
minimally-invasive spine procedures
that combine efficiency, safety and
quicker recovery of patients. Thus, our
Spine Center has all existing surgical
resources available in the market.
As important as any of the actions
mentioned above, we have yielded
results from the use of protocols and
procedures that impact quality of care
and patient safety. This report brings
many outcome indicators that confirm
our alignment with the international
benchmark. One of them is the low
surgical site infection rate in orthopedic
procedures. In 2016, the rate was 0.17 –
even lower than in previous years (0.4
in 2014 and 0.3 in 2015). Just to take it
into perspective, the literature indicates
world infection rates in orthopedic
surgeries ranging from 1 and 2.5%.
This publication also presents the
information that showcases our
vitality in teaching, research and
social responsibility activities. Seen
as a whole with our clinical activities,
they show that we have set a virtuous
cycle in orthopedics, adding value to
our patients, the society and medical
practice, helping to pave the future of
orthopedic medicine.
We hope you enjoy the reading.
Mario Ferretti, MDMedical Manager of the Locomotor Program, Hospital Israelita Albert Einstein
This report brings many outcome indicators that confirm our alignment with the international benchmark. One of them is the low surgical site infection rate in orthopedic procedures.
7
8
OverviewHospital Israelita Albert Einstein
2.7% Increase in number of
outpatient visits
6.6% Increase in number
of credentialed physicians at
Einstein
16.5% Increase in performed
surgical procedures
Hospital Israelita Albert Einstein
Medicina Diagnóstica
e Ambulatorial (Diagnostic
and Outpatient Medicine)
Instituto Israelita de
Ensino e Pesquisa (Teaching and
Research)
Instituto Israelita de
Responsabilidade Social (Social
Responsibility)
Instituto Israelita de Consultoria
e Gestão (Consulting
Management)
Einstein facts and figures 2015 2016 Variation %
Number of operational beds 615 646 5.04%
Number of ICU beds (Adults) 44 40 -9.09%
Number of patients/ day 196.726 185.949 -5.48%
Mean length of stay (in days) 3.91 3.51 -10.23%
Occupancy rate 84.86% 82.57% -2.70%
Hospital Discharges Total - Morumbi
- Vila Mariana- Perdizes-Higienópolis
53,25253,128
1195
52,97552,969
06
-0.52%-0.30%
-100.00%20.00%
Surgical procedures Total - Morumbi
- Perdizes-Higienópolis
43,77842,262
1,516
51,03148,520
2,511
16.57%14.81%
65.63%
Deliveries 4,669 4,295 -8.01%
Tests Total- Morumbi
- Alphaville- Jardins
- Ibirapuera- Perdizes-Higienópolis
- Cidade Jardim
7,711,1106,248,813443,283448,349570,665714,26734,387
7,060,1255,565,717
408,127450,746635,535674,643
37,651
-8.44%-10.93%-7.93%0.53%11.37%
-5.55%9.49%
Visits (Outpatients) Total- Morumbi
- Alphaville- Perdizes
304,517242,098
46,33216,087
313,001242,893
49,35220,756
2.79%0.33%6.52%
29.02%
ED Visits Total- Morumbi
- Centro Médico Ambulatorial (CMA)
- Oncologia- Alphaville- Ibirapuera
- Perdizes-Higienópolis
331,504130,977
1,582458
55,42282,35060,715
335,667131,135
1,092703
55,72786,251
60,759
1.26%0.12%
-30.97%53.49%
0.55%4.74%0.07%
Number of credentialed physicians:Staff (hired employees)
7,73512,755
8,25212,929
6.68%1.36%
Hospital Israelita Albert Einstein is a not-for-profit general hospital focused on high complexity and capable of covering all healthcare dimensions: promotion, prevention, diagnosis, treatment and rehabilitation.
9
10
9,098 hospital
discharges
39,294 orthopedic
medical visits
8,930 orthopedic surgeries
performed in 2016
OverviewEinstein Orthopedics
Surgical specialty
Surgical procedure 2015 2016 Variation %
Bucomaxillofacial Surgery
Bucomaxillofacial Surgery 1,370 923 -33%
Maxillary sinusectomy – endonasal access 456 743 63%
Videolaparoscopic intranasal ethmoidectomy 503 658 31%
Intranasal ethmoidectomy 278 623 124%
Videolaparoscopic sphenoidal sinusotomy 306 391 28%
Intranasal maxillary anthrostomy 228 462 103%
Sphenoidal sinusotomy 216 464 115%
Intranasal frontal sinusotomy 173 454 162%
Videolaparoscopic intranasal frontal sinusotomy 232 297 28%
Videolaparoscopic intranasal maxillary anthrostomy 165 151 -8%
Videoendoscopic endonasal maxillary sinusectomy 162 111 -31%
Transmaxillary sinusectomy (Ermiro de Lima) 45 79 76%
Orthopedics and Traumatology
Diagnostic arthroscopy with/ without synovial biopsy
291 369 27%
Tenolysis of osteofibrous tunnel 147 203 38%
Surgical debridement of wounds or extremities 220 129 -41%
Transposition of more than 1 tendon – surgical treatment
130 200 54%
Single microneurolysis 110 190 73%
Arthroplasty (any technique or hip version) - surgical treatment
113 144 27%
Tenoplasty/ tendon grafting – surgical treatment 111 119 7%
Segmented percutaneous rhizotomy – any method 101 116 15%
Fracture and/or dislocation (including elbow-wrist epiphyseal detachment) - surgical treatment
80 107 34%
Osteotomy or pseudoarthrosis of metatarsus/ phalanges – surgical treatment
83 96 16%
NUMBER OF ORTHOPEDIC SURGERIES – KEY PROCEDURES
11
12
Locomotor Program
The Locomotor Program is a strategic area focused on orthopedics and rheumatology that
works in matrix with all clinical areas of Hospital Israelita Albert Einstein, Medicina Diagnostica e
Ambulatorial (Diagnostic and Outpatient), Instituto Israelita de Ensino e Pesquisa (Teaching and
Research), Instituto Israelita de Responsabilidade Social (Social Responsibility), Instituto Israelita
de Consultoria e Gestão Corporativo (Consulting Management). Its main goal is to manage
orthopedics in all its arenas by means of designing and implementing institutional protocols,
control of indicators, and strategic plans that promote growth and continuous improvement,
in addition to managing innovative projects, such as the second opinion program for spine and
cranial maxillofacial surgery.
The actions of the Locomotor Program are guided to patient quality and safety, management of
the clinical staff, social responsibility and sustainability, teaching, research and innovation.
FLOW CHART OF LOCOMOTOR PROGRAM 2016
Dr. Mario Ferretti
Medical Manager
Dr. Mario Lenza
Medical Coordinator
Gerusa Silva
Administrative technical assistant
Thais Rosa
Administrative technical assistant
Renata Lima
Administrative technical assistant
Vanuza de Oliveira
Administrative technical assistant
Isabela Paião
Nurse
Luciana Machado
Nurse
Eliane Antonioli
Researcher
13
14
Timeline
• Management of
hip protocol
• Management
of knee
protocol
• Spine
Excellence
Center
• Opening of
orthopedic
offices
• Implementation
of Locomotor
Program
• Standardization
of spine materials
• Medical Residency
Program
• Multidisciplinary
Graduate Program
• Spine Guidelines
• Cranial Maxillofacial
Project
• Foot Center
• Design of the Spine
Protocol and Manual
• Home Care Program
for Total Knee
Arthroplasty (TKA)
• Outcomes for TKA
• Anterior cruciate
ligament (ACL) protocol
• Beginning of
management of ACL
• Interruption of
prophylactic
antibiotics within
24 hours for TKA
and THA (Total Hip
Arthroplasty)
• Outpatient flow
for simple knee
arthroplasty
• Beginning
of Cranial
Maxillofacial
Project
• Management and
standardization
of materials (oral,
spine, arthroplasty
and arthroscopy)
• Actions to
prevent infections
in orthopedic
surgeries
• Acquisition of
the new spine
endoscopy
2007 2008 2009 2010 2011 2012 2013 20152014 2016
15
16
Service Structure and Volume
HOSPITAL ISRAELITA ALBERT EINSTEIN ORTHOPEDICS
Different areas of the Hospital are important for the diagnosis and care of orthopedic patients.
The main ones are:
1. Emergency Department
2. Medical offices
3. Diagnostic and Outpatient Care
4. Rehabilitation Center Gisele and Jacques Szlezynger
5. Operating Suite and Day Clinic I4
6. Inpatient unit – 11th floor, Building A
1. EMERGENCY DEPARTMENT
The Emergency Department is ready to provide comprehensive and high-level
care to patients with orthopedic trauma disorders. It has an orthopedic backup
team that is frequently trained and updated to promote the best care to patients.
The units are divided into strategic sites, such as Morumbi, Perdizes, Alphaville
and Ibirapuera.
Medication room, Emergency Department
Central nursing station
Mobile unit to transfer urgency and emergency patients
Care provided in the mobile unit during transfer of urgency and emergency patients
17
18
Number of orthopedic visits per Emergency
Department Unit
9,47210,210
9,313
3,9804,0263,302
4,6794,826
5,948
18,69618,190
16,786
UPA Morumbi UPA Ibirapuera UPA Alphaville UPA Perdizes
2014
2015
2016
2. ORTHOPEDIC MEDICAL OFFICES – 3RD FLOOR BUILDING A1
The Outpatient Medical Center has seven rheumatologists and 48 orthopedists in all
orthopedic subspecialties, such as spine surgeons, shoulder and elbow, hand, hip, knee,
foot and ankle surgeons, in addition to trauma and pediatric orthopedic surgeons.
The Orthopedics Program has proposed to the clinical staff and the orthopedic medical
board to create groups of subspecialties. These groups develop protocols and guidelines
for diagnosis and treatment, promoting discussion of clinical cases and standardizing
case management, in addition to helping with the training of Orthopedics and Trauma
resident physicians at Einstein. Medical office at the Outpatient Center
19
20
Procedure room at the Outpatient Center
2009
22,471
2011
40,724
2010
30,735
2013
43,564
2014
43,610
2015
43,117
2012
42,900
2016
39,294
Number of orthopedic visits – Unit Morumbi
Number of orthopedic visits – Unit Morumbi
Orthopedic visits have reached a plateau, stabilized due to the pre-defined occupancy.
However, as shown in the chart below, the orthopedic visits represent a number of about
40,000 visits per year in the Outpatient Medical Center.
3. DIAGNOSTIC MEDICINE
The Outpatient and Diagnostic Medicine team at Einstein works in an integrated
fashion and uses latest generation equipment, providing medical follow up and all
imaging and laboratory tests. Einstein has many units around the city of Sao Paulo
and in Alphaville.
X-RAY
X-ray is a test that exposes part of the body to a small amount of ionizing radiation
to produce images from inside the body. It is used to assess bone abnormalities,
to detect foreign objects, assess lesions such as fractures or damage caused by
infections, arthritis, abnormal bone growth or osteoporosis, to guide orthopedic
surgeries, such as vertebral spine repairs, joint replacements or fracture reductions,
to determine if there is fluid buildup in the joint and around the bone, to ensure
that a fracture has correctly healed and to check whether a bone is fractured or a
joint is displaced.
Patient submitted to hip x-ray
21
22
COMPUTED TOMOGRAPHY SCAN
Computed tomography scan (CT) is a diagnostic method that uses x-rays to take images from
different parts of the body. However, differently from conventional x-rays, which take a panoramic
view of part of the body to be studied, CT scan acquires sliced sections of our body. These sections
are disposed on the computer screen and then photographed. Thus, CT scan technology produces
much clearer images than conventional x-ray.
Computed tomography device
Ultrasound device
MAGNETIC RESONANCE IMAGING
Magnetic resonance imaging (MRI)
is a test that portrays our organs
in high-definition images, through
the use of a magnetic field.
One of the differentials of the test
is the capacity to visualize the
so-called soft tissues. The technique
is especially effective in the diagnosis
of muscle, tendon and ligament
diseases. The test is capable of
tracing disorders by scanning the
anatomy of the internal structures.
To reach such level of preciseness,
the technology is one of the most
complexes among imaging tests.
ULTRASOUND
Ultrasound (US) provides the assessment of traumatic lesions in soft parts, such as
muscles, tendons and ligaments, as well as the characterization of occult fractures
and foreign bodies. It is a method that does not use any type of radiation and does
not have side effects.
Being dynamic, the ultrasound enables the examiner to reach additional information
about muscle or tendon tears by asking the patient to make flexions or extension of
the joint. The physician may observe the behavior of the damage in movement.
Magnetic resonance device
23
24
4. REHABILITATION CENTER GISELE AND JACQUES SZLEZYNGER
The Rehabilitation Center Gisele and Jacques Szlezynger at Einstein was
opened in May 2013, being a pioneer in the integration of this type of service
in a high-complexity general hospital. To present, it is a national reference
in rehabilitation. Housed in a pleasant 2,000 m2 area, the center has latest
generation devices and a highly qualified team. There are 119 professionals,
being 16 physical therapists and three occupational therapists.
Orthopedic rehabilitation focuses on musculoskeletal dysfunctions such as
vertebral spinal diseases, joint sprains, muscular damage and postoperative
care after orthopedic surgeries, among other chronic, recurrent or acute
diseases. Physical therapy has the role to control pain and restore the
impaired function, in addition to educate the patient about care and
precautions to be taken in daily living activities and sports practice.
Orthopedic care has been continuously growing and in 2016 it showed 4% increase
compared to 2015. This progress is an indication of the commitment and quality of
the care provided.Gymnasium of the Rehabilitation Center
Stationary bikes at the Rehabilitation Center
2011
20,611
2012
22,264
2013
24,438
2014
27,121
2015
34,156+4%
2016
35,655
Number of visits
HIGH TECHNOLOGY QUALITY EQUIPMENT
Stationary bikes equipped
with monitoring
The bikes simulate
movements but do not
cause impact on joints,
muscles and tendons,
favoring the execution of
physical activities in people
with joint problems.
The benefits include easier
limb movement, improving
blood circulation and
strengthening lower limb
muscles.
25
26
Gait trainer
The device provides safe functional gait
training. Using a hanger, it enables early
gait practice, with no risk of fall.
The purpose of the equipment:
• Provide early orthostatic position;
• Improve symmetry of the right and
left step;
• Improve the pace of the gait;
• Improve symmetrical weight bearing
on the lower limbs;
• Useful in rehabilitation of lower
limb surgeries, such as hip and knee
surgeries.
Equipment in the gymnasium of the Rehabilitation Center Swimming pool for hydrotherapy at Rehabilitation Center Gisele and Jacques Szlezynger
HYDROTHERAPY
It is an extremely
relevant therapeutic
resource to treat many
diseases, including
musculoskeletal
disorders, and can be
used in many subareas
of physical therapy.
Applied in a warm pool,
hydrotherapy intends
to prevent diseases,
promotes and maintains
health, treat, cure and
rehabilitate functional
muscle disorders and reintegrates the subject back into society by using specially
developed techniques.
The artificial structure that houses the water reservoir and the attached areas
provides to patients and professionals the appropriate working conditions,
hygiene, accessibility, comfort and safety, which favor logical, reliable and
efficient outcomes. Therapeutic exercises in the swimming pool minimize
problems resulting from several physiological, mechanical and psychological
alterations and transformations.
27
28
LEME – MOVEMENT STUDY LABORATORY
LEME – Laboratorio de Estudo do
Movimento Einstein (Einstein Movement
Study Laboratory) was devised to measure
and describe gait. Infrared cameras,
strength platforms, reflective markers,
electromyography and software are offered
as part of the advanced technology used by
Leme. The technology provides the precise
analysis of movement, identifying possible
abnormalities and facilitating the diagnosis
and treatment of patients with gait disorders
or neurological problems.
The process of movement analysis starts
from orthopedic and neuromuscular physical
examination of the patient, followed by
5. OPERATING SUITE AND DAY CLINIC I4
Einstein Surgical Unit has two Operating Suites and Central Sterilization and
Supplies Departments located in separated areas. The Operating Suite works 24
by 7 and has material available for the performance of all procedures, including
emergency situations, which enables performance of high complexity surgeries
with quality and safety.
OPERATING SUITE OF PAVILION VICKY AND JOSEPH SAFRA – BUILDING A1
The set of biomedical clinical engineering resources provides the performance of
imaging-guided minimally invasive surgeries, combined or not with conventional
procedures, in addition to enabling treatment and diagnosis to be performed
simultaneously. There are 18 surgical rooms and nine of them have video for
arthroscopic surgeries.
The same area houses Day Clinic I4, intended for minor surgery patients. There is
a considerable number of orthopedic surgeries performed as an outpatient flow.
Between April and May 2015, we started the outpatient flow for simple knee
arthroscopy. Well-accepted by physicians, the action generates faster flow to
patients, who start the process of rehabilitation in the anesthetic recovery room.
Percentage of compliance with the outpatient flow for
simple knee arthroscopy
0%
Jan/1
5
0%F
eb
/15
0%M
ar/
15
25%
Beginning of outpatient flow
Ap
r/15
0%
May
/15
33%
Jun/1
5
20%
Jul/
15
69%
Aug
/15
50%
Sep
/15
65%
Oct
/15
43%
No
v/15
90%
Dec/
15
67%
Jan/1
6
71%
Feb
/16
100%
Mar/
16
88%
Ap
r/16
73%
May
/16
67%
Jun/1
6
50%
Jul/
16
67%
Aug
/16
83%
Sep
/16
100%
Oct
/16
93%
No
v/16
70%
Dec/
16
weight and height measures and placement of
markers and/or electrodes on the skin.
While the patient walks along the laboratory
track, a video recording is made for
observational analysis. Simultaneously, the
computer documents kinematic, kinetic and
dynamic electroneuromyography data. The
process is monitored by a biomechanical
specialized engineer, which starts data
processing.
This study guides technical corrections for
specific sports, such as running, in addition
to indicating surgeries for patients with
cerebral palsy, recommending the muscle
groups that require surgical repair.
29
30
Hybrid Room
The Hybrid Room at
Hospital Israelita Albert
Einstein spreads on 180m2
and combines state-of-
the-art technology that
provides the performance
of high complexity
procedures, in addition to
having imaging devices
for minimally invasive
techniques done with
maximum precision and
high level of safety.
OPERATING SUITE ON THE 5TH FLOOR - EDIFICIO MANOEL TABACOW HIDAL – BUILDING D
This Operating Suite has 14 rooms, equipment for all specialties, including trauma and orthopedic
procedures
The chart above shows the stabilization of high complexity surgeries, such as hip,
knee and shoulder arthroplasty, spine fusion and other major surgical procedures
that require the use of medical and hospital resources, braces, implants and special
materials.
In 2016, there was 30% increase in number of orthopedic surgeries performed at Unit
Morumbi, compared to the previous year.
2012
4,991
2013
4,846
2014
4,820
2015
6,594
2016
8,558
Number of surgical procedures – Unit Morumbi
2010 2011
29%
42%
2012
36%
2013 2014
60%64%
2015
65%
2016
68%
Rate of high complexity procedures
31
32
At Unit Perdizes, there has also been increase in number of surgeries. This advance
results from the strategic location of the unit and the availability of schedule and
resources.
Spine and tumor surgeries amounted to most of the 31% increase in surgical volume.
In 2016, the number of orthopedic surgeries in both units showed 31% increase
compared to 2015.
2012
2012
217
5,208
2013
2013
217
5,063
2014
2014
207
5,027
2015
2015
227
6,821
2016
2016
372
8,930
Number of surgical procedures – Unit Perdizes Number of surgeries by subspecialty – Unit Morumbi
Number of surgical procedures – Units Morumbi and Perdizes
6. INPATIENT UNIT – 11TH FLOOR, BUILDING A
The Orthopedic Inpatient Unit is located on the 11th floor of Building A, with 36 beds,
two nursing stations and a reception area. The multiprofessional team is formed by 23
registered nurses, 35 nursing technicians, 10 nursing assistants, 13 physical therapists,
one psychologist, one dietitian and one pharmacist.
Nursing station of the Orthopedic Inpatient Unit Room of the Orthopedic Inpatient Unit
110211229
299
478536
807911
1,116
157259
579
388
552522
941
1,4471,370
1,015
225
1,0201,001
451325
771923
1,458
Knee Shoulder OthersWrist and hand
Ankle and foot
HipTrauma Spine Tumor
2014 2015 2016
33
34
Clinical Staff
The Clinical Staff of Orthopedics and Rheumatology is comprised of 673 physicians, divided into 604 orthopedists, 45 rheumatologists and 24 physiatrists.
Measuring a set of criteria comprised of over 70 indicators, there is constant assessment
of the physicians in the Clinical Staff.
These criteria are distributed into four main pillars: Quality, Volume of Care, Teaching
and Research and Social Responsibility and the physicians can check them by clicking
on “My Outcomes” (Meus Resultados).
QUALITY
• Completion of medical records;
• Compliance with protocols and clinical
practices;
• Continuing Medical Education (CME);
• Relationship Survey (Multiprofessional
team);
• Medical Occurrences (complaints and
compliments made to the Customer
Care);
• Compliance with administrative routines
(discharge, surgery cancellation, first
surgical time, length of stay in managed
procedures, clinical pre-scheduling).
TEACHING AND RESEARCH
Indicator from Instituto Israelita de
Ensino e Pesquisa (Teaching and
Research)
• Participation in research, teaching and
training activities at SBIBAE.
VOLUME OF CARE
• Encounters (admissions and tests);
• High complexity encounters;
• Time of credentialing at Hospital
Israelita Albert Einstein;
• Exclusive credentialing at Hospital
Israelita Albert Einstein;
• Internal referrals at Hospital Israelita
Albert Einstein.
SOCIAL RESPONSIBILITY
Participation in voluntary/ non-paid
activities:
• Non-paid admissions and surgeries;
• Transplant, Cardiology and Neurology
programs;
• Medical Boards;
• Page Epoca;
• Support to digital media.
35
36
MEDICAL INDICATOR
Einstein has a Medical Indicator, developed based on merit criteria.
This is also a tool to encourage the adoption of best practices and the
involvement with the organization.
Access to Medical Indicator can be made through the website www.
einstein.br or the Call Center (55 11) 2151-1233.
The Orthopedics Medical Indicator includes pediatric, shoulder and
elbow, hip, knee, foot, hand, spine and general orthopedics and trauma
specialists.
Based on the score of these pillars, the physicians are classified into the segmentation
Premium, (AAA), Advanced (A), Evolution (B), and Special (C). In 2016, we had 37 Premium
(AAA), 66 Advance (A), 154 Evolution (B) and 416 Special (C) professionals.
We maintain close relationship with our Clinical Staff through meetings of
subspecialties, breakfasts, clinical meetings, medical residency programs, orthopedic
and rheumatology forums and feedback sessions.
Focusing on continuous improvement of processes and excellence in quality, since 2008
we have had medical feedback sessions in partnership with Medical Quality and Health
Economics. It promotes in-person meetings between physicians and the team members
of Medical Quality, Health Economics and Locomotor Program, in order to provide
information about their practice in the organization.
In 2016, we carried out 100% feedback sessions in the Spine Program and 100%
feedback sessions for physicians involved in the managed protocols of hip and knee
arthroplasties.
Evolution of the Medical Segmentation
5680
66
154171
154
279
362
416
29 27 37
Premium (AAA) Advance (A) Evolution (B) Special (C)
2014
2015
2016
37
38
Quality and Clinical Outcomes
MANAGED PROTOCOL OF HIP ARTHROPLASTY
Since 2008, the Locomotor Program has managing patients submitted to
hip arthroplasty. The objective is to ensure safety and quality, in addition
to monitor their progression during pre, intra and post-hospital care.
The protocol has been designed and reviewed by orthopedists, nurses,
physical therapists and occupational therapists, based on best practices
and literature evidence.
NUMBER OF HIP ARTHROPLASTY SUGERIES
In 2016, the volume of total hip arthroplasty has been stable, confirming
the surgical complexity of orthopedics and evidencing the reflexes of
population aging.
2010 2011
107
132
2012
144
2013 2014
189182
2015
187
2016
179
Surgical volume – Hip Arthroplasty
Epidemiology – Distribution of patients that have undergone hip
arthroplasty by age range in 2016
31.4%
0.5%
59.1%
9.1%
0-25 years
26-45 years
46-65 years
>65 years
39
40
Rate of antibiotic administered up to 60 minutes before
surgical incision – Hip Arthroplasty
MEAN LENGTH OF STAY
As a result of pre and post-operative home care visits to patients, the mean length
of stay is decreasing, still maintaining safety and quality of care, following the
example of what happens in Europe and the United States.
Patients eligible to undergo total hip arthroplasty are visited by the Home Care
team before the procedure to help them adapt their houses and for general
education. After hospital discharge, the same team makes two other visits to
ensure the necessary general care required for patient recovery.
PROPHYLACTIC ANTIBIOTIC INDICATOR
This indicator is divided into three items: antibiotic administered up to 60 minutes
before the incision, choice of correct prophylactic antibiotic, and suspension of
antibiotic within 48 hours.
This is an extremely important indicator because it refers to infection prevention.
Efficacy of prophylaxis is directly related to correct choice and mode of
administration of the medication (which should be performed within 60 minutes
before surgical incision to ensure the peak concentration of the antimicrobial
agent at the time the tissues are exposed).
In 2015 and 2016, the Locomotor Program proposed discussions about the topic
and promoted an active action of the nurses and pharmacists of the inpatient
units close to patients that were submitted to surgery. As a consequence, almost
all surgeons comply with prophylactic measures against postoperative infection.
2010
2010
2011
2011
6.19
92%
6.25
84%
2012
2012
5.69
98%
2013
2013
2014
2014
5.12
98%
4.23
96%
2015
2015
3.79
98%
2016
2016
3.52
99%
Rate of correct antibiotic – Hip Arthroplasty
2010 2011
92%100%
2012
100%
2013 2014
100% 100%
2015
100%
2016
100%
Mean length of stay – Hip Arthroplasty
41
42
In 2015, the team adopted the recommendation to interrupt prophylactic antibiotic
within 24 hours after the first dose, as the antibiotic has no additional role to play
and its continuous use increases the risks of medication-resistant microorganisms.
Rate of prophylactic antibiotic interruption within 48 hours
– Hip Arthroplasty
Rate of prophylactic antibiotic interruption within 24 hours
– Hip Arthroplasty
2011
19%
2012
65%
2013
96%
2014
95%
2015
98%
2016
100%
2015
57%
2016
92%
INFECTION RATE
The surgical site infection rate is an important indicator. Orthopedics has focused on
reducing the risks of infection and adopting the appropriate antibiotic for prophylaxis,
which provides more safety to patients.
The annual mean rate of infection in total hip arthroplasty at Einstein is 0.6%, lower than
the world literature1.
1. Pruzansky JS, Bronson MJ, Grelsamer RP, Straus E, Moucha CS. Prevalence of modifiable surgical site infection risk factors in hip and total knee arthroplasty. ARD Online First, 2011, 10.1136/ard.2010.148726.
COMPLIANCE WITH VENOUS THROMBOEMBOLISM PREVENTION PROTOCOL
Deep venous thrombosis is the obstruction of deep veins by a thrombus (blood clot)
and its most severe complication is pulmonary embolism, which may cause respiratory
and circulatory difficulties and may even lead to cardiac arrest. Among the risk factors
for thromboembolism we may include reduced mobility, prolonged surgical time and
age older than 45 years. In general, these conditions are presented by hip arthroplasty
patients. However, as an intra-hospital practice, we use the prevention protocol, which
has shown good compliance.
READMISSION RATE WITHIN 30 DAYS
The low rate of readmissions shows that the quality of care at Einstein contributes to
good patient outcomes.
Rate of compliance with venous thromboembolism protocol
– Hip Arthroplasty
2010 2011
98% 98%
2012
97%
2013 2014
99% 99%
2015
100%
2016
100%
Readmission rate within 30 days – Hip Arthroplasty
2010 2011
0.0%0.8%
2012
0.7%
2013 2014
0.5% 0.5%
2015
1.0%
2016
0.6%
43
44
OUTCOMES OF HIP ARTHROPLASTY PATIENTS
In partnership with Einstein Outcomes Center, the Locomotor Program follows
up patients after hospital discharge. The patients answer questionnaires before
the admission and, after discharge, they receive periodic calls to answer the same
questionnaires in order to analyze their progression and possible complications
throughout the years. There are two questionnaires that are used to monitor
patients submitted to total hip arthroplasty: EuroQoL and Womac.
EuroQoL is a simple and general questionnaire, comprised of two main
components. The first one defines health-related quality of life (HR-QoL) in five
dimensions: mobility, self-care, usual activities, pain/ discomfort and anxiety/
depression. The second component consists of a numbered Visual Analog Scale
(VAS) ranging from 0 to 100, in which zero is the worst imaginable health status
and 100, the best.
WOMAC
The Western Ontario and McMaster Universities (Womac) is a functional scale of
affected joints and it assesses intensity of pain, rigidity and functionality grade.
We have observed significant improvement after two years of follow up (the lower
results indicate the better outcomes).
Pre 30 days
0.439
650.721
78
60 days
0.802
82
90 days 6 months
0.826
82
0.839
83
1 year
0.844
84
2 years
0.82784
Quality of Life
EQ-5D
Visual Analog Scale
MANAGED PROTOCOL OF KNEE ARTHROPLASTY
The knee arthroplasty protocol was implemented one year after the success of the hip
protocol, following the same assumptions.
2010 2011
69
88
2012
81
2013 2014
106 104
2015
109
2016
84
Surgical Volume - Knee Arthroplasty
Pre 30 days
46.1
27.9
60 days
19.6
90 days 6 months
14.811.6
1 year
10.6
2 years
9.9
WOMAC
BETTER
45
46
Distribution of patients who have undergone Knee Arthroplasty by
age range up to 2016
0-25 years
26-45 years
46-65 years
>65 years28.4%
0.6%
68.5%
2.4%
MEAN LENGTH OF STAY
The mean length of stay has been decreasing gradually, which improves intra-hospital
care and enables the patient to quickly resume daily activities.
In 2014, we started Einstein Home Care Program for patients submitted to total knee
arthroplasty (TKA). It has helped reduce length of stay and maintain safety and quality
of care, following the example of the best hospitals abroad. The process is the same
that has been adopted by patients submitted to hip arthroplasty (see page 40).
RATE OF PROPHYLACTIC ANTIBIOTIC
Similarly to the previous year, the rate of antibiotics administered up to one hour
before surgical incision reached 99%. Equally expressive are the rates of correct
antibiotic and interruption within 48 hours after the procedure, which reached 100%.
2010
2010
20102011
2011
2011
6.21
99%
100%5.96
71%
92%
2012
2012
2012
5.95
91%
93%
2013
2013
20132014
2014
2014
4.90
99%
100%
4.06
98%
100%
2015
2015
2015
3.96
99%
100%
2016
2016
2016
3.94
99%
100%
Mean length of stay – Knee Arthroplasty
Rate of antibiotic up to 60 min before surgical incision –
Knee Arthroplasty
Rate of correct antibiotic prophylaxis – Knee Arthroplasty
47
48
Rate of prophylactic antibiotic interruption within 48 hours
– Knee Arthroplasty
Rate of antibiotic prophylaxis interruption within 24 hours
– Knee Arthroplasty
2015
45%
2016
88%
2010 2011
45%51%
2012
56%
2013 2014
86%
95%
2015
100%
2016
100%
COMPLIANCE WITH VENOUS THROMBOEMBOLISM PREVENTION PROTOCOL
For two consecutive years, the compliance rate with this protocol has reached
100%, preventing deep venous thrombosis and its complications (see explanation
on page 43).
READMISSION RATE WITHIN 30 DAYS
In 2016, there was no case of readmission within 30 days after hospital discharge.
2010 2011
100%93%
2012
99%
2013 2014
99% 99%
2015
100%
2016
100%
Rate of compliance with venous thromboembolism
protocol – Knee Arthroplasty
Rate of readmission within 30 days – Knee Arthroplasty
2010 2011
0%
4%
2012
0%
2013 2014
2%0%
2015
0.9%
2016
0%
49
50
OUTCOMES OF KNEE ARTHROPLASTY PATIENTS
In partnership with Einstein Outcomes Center, the Locomotor Program follows
up patients after hospital discharge. The patients answer questionnaires before
the admission and, after discharge, they receive periodic calls to answer the same
questionnaire in order to analyze their progression and possible complications
throughout the years.
Visual analog scale (VAS) - Pain
Direct measuring technique that gives the patient the chance to score pain (0 means
total absence of pain and 10 represents the worst possible pain).
Utility - EuroQol
As explained before, one of the components of EuroQoL is the questionnaire that
assesses quality of life.
KOOS - Knee injury and Osteoarthritis Outcome Score
KOOS is directed to patients with knee lesions, such as osteoarthritis, meniscal
lesions, anterior cruciate ligament lesion, among others. It has five subscales: pain,
symptoms, daily living activities, sports and quality of life related to the knee. The
answers are standardized and each question is given a score from 0 (extreme
symptoms) to 100 (no symptoms).
Pre
6
6 months
2
1 year
1
2 years
2
Pain Visual Analog Scale – Knee Arthroplasty
BETTER
Pre
0.495
6 months
0.801
1 year
0.871
2 years
0.867
Quality of Life – Knee Arthroplasty
BETTER
KOOS
Pain
49
8186 87
56
8388
91
47
7983
90
21
2834
56
22
6872
77
Symptoms Daily living activities
Sports Quality of life related to the knee
Pre
6 months
1 year
2 years
HOME CARE PROJECT The Locomotor Program, in partnership with the Home Care area, has implemented a
pre and post-surgical home visit to ensure safe discharge from hospital. The project
started in 2012, with hip arthroplasty and, in 2014, we started the action with knee
arthroplasty. Both specialties experienced very positive results.
The charts that follow show that length of stay was shorter for patients who received
visits before the surgery.
51
52
MANAGED PROTOCOL OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
Implemented in 2014, this protocol standardized the procedure to reconstruct
the anterior cruciate ligament (ACL) based on scientific evidence to ensure the
best outcomes.
Greatly associated with practicing sports, such as basketball, skiing and soccer,
the latter very prevalent in Brazil, ACL damage affects mainly young active adults.
The patients with indication for surgical reconstruction of the ACL lesion are
eligible to this protocol.
As shown in the charts below, the number of surgeries has been stable, as well as
the length of stay of 1 to 1.2 days, which is ideal to this kind of procedure.
Mean length of stay – Home Care Program – Hip Arthroplasty
Mean length of stay – Home Care Program – Knee Arthroplasty
Did not receive pre-procedure visit
4.41
Received pre-procedure visit
3.85
4.183.74
Distribution of patients who have undergone anterior cruciate
ligament reconstruction surgery
Number of surgeries – Anterior Cruciate Ligament Reconstruction
Jul-Dec/2014
118
2015
274
2016
256
0-25 years
26-45 years
46-65 years
>65 years
23.9%
17.1%
0.2%
58.8%
Did not receive pre-procedure visit
Received pre-procedure visit
53
54
Mean length of stay - Anterior Cruciate Ligament
Reconstruction Surgery
Rate of antibiotic up to 60 min before surgical incision – Anterior
Cruciate Ligament Reconstruction Surgery
Rate of correct antibiotic prophylaxis – Anterior Cruciate Ligament
Reconstruction Surgery
Rate of antibiotic prophylaxis interruption within 24 hours – Anterior
Cruciate Ligament Reconstruction Surgery
Rate of readmission within 30 days – Anterior Cruciate Ligament
Reconstruction Surgery
Jul-Dec/2014
Jul-Dec/2014
Jul-Dec/2014
Jul-Dec/2014
Jul-Dec/2014
1.16
91%
100%
80%
0%
2015
2015
2015
2015
2015
1.12
95%
100%
76%
0%
2016
2016
2016
2016
2016
1.2
99%
100%
85%
0%
MEAN LENGTH OF STAY
RATE OF PROPHYLACTIC ANTIBIOTIC
The adoption of the protocol and many other dissemination and education actions
focused on the multidisciplinary team have contributed to continuously improving
the antibiotic prophylactic rate. The charts that follow show the administration of
the correct antibiotic, within one hour before the surgery, and its interruption within
24 hours after the procedure.
READMISSION RATE WITHIN 30 DAYS
Since the day the protocol was implemented in 2014, there has been no case of
patient readmission within 30 days from discharge after anterior cruciate ligament
reconstruction surgery.
55
56
SPINE PROGRAM
The purpose of the Spine Program is to provide safe second opinion, carefully
assessing the need for surgery. The hospital offers multiprofessional care, including
physiatrist, orthopedist and, if necessary, spinal surgeon. If the surgeon confirms
the need for surgery, the case is discussed in the Spine Board, which will reach a
consensus on the best procedure to be offered to the patient.
This clinical flow has been created to transparently show that surgical indications are
being made to offer the best to the patient and always based on professional ethics.
The project has been created to serve patients who own healthcare insurance plans
which otherwise would not have access to Einstein services. Once the diagnosis and
most appropriate treatment are defined (conservative or surgical management), the
patient can decide to undergo it or not.
Considering medical practice, the program favors ethical behaviors, as the patient
has the possibility to receive a second opinion about the disease treatment and
can learn more about it. The second opinion is impartial and the final management
has to be approved by the patient. The whole process is also ruled by an informed
consent document that is signed by the patient.
Since the creation of the program, in 2011, 7,092 patients have been referred to it
and 3,933 were fully assessed. A total of 59% of the cases were defined as non-
surgical, that is, the patients could benefit from conservative treatment.
Out of 2,303 patients who had surgical indication, 1,061 decided to undergo the
procedure at Einstein.
Referrals to Spine Project
2011
166
2012
931
2013
1,742
2014
1,404
2015
1,417
2016
1,432
Indication of Treatment at Einstein – General
n=3,933
General Surgical Management
General Conservative Management
1,630(41%)
2,303(59%)
57
58
As a result of enhanced confidence and increase in number of patients referred to
be assessed, the number of surgical procedures has been increasing throughout the
years in the Spine Program, as shown by the chart below.
Standardization and scientific-evidence based protocols guide the management of
specialists in the Spine Board, providing continuous improvement of quality of care and
increasing the referrals and performed procedures.
The chart below compares the main surgical techniques for spine degenerative
diseases – more invasive interventions (fusions) and less invasive interventions (surgical
decompression), indicating increase of the latter.
The mean length of stay includes all surgeries performed by the Spine Program, including
decompressions, fusions and spine surgery revisions. The quarterly feedback actions have
contributed to reduce length of stay throughout the years.
In 2014, we started performing outpatient facet infiltrations in the Interventional Radiology
Center of the hospital. The procedure is performed by a specialized radiologist, after case
discussion with the patient’s surgeons. Due to this new flow, there is no need for hospital
admission. It reduces the risk of infections or complications and patients can quickly resume
their regular activities.
2013
100%
2014
100%
2015
99%
2016
100%
Compliance with Spine Guidelines
LUMBAR SPINE GUIDELINES
Supported by the Spine Board, in 2013 the Locomotor Program created the
guidelines for treatment of the main vertebral spine degenerative diseases. These
guidelines have significantly changed surgical indications, favoring the use of less
invasive techniques without implant materials, which provide faster patient recovery
and outcomes that showed improvement in patient quality of care.
Annual Surgical Volume – General
Mean length of stay – Spine Program
Comparison between Fusions and Lumbar Decompressions
2011
2011
20
3.7
2012
2012
136
3.1
2013
2013
165
2.6
2014
2014
180
2.2
2015
2015
245
1.9
2016
2016
315
1.5
n=1,061
2011
45%
55%
2012
59%
41%
2013
24%
76%
2014
18%
82%
2015
78%
22%
2016
10%
90%
Lumbar Decompression
Lumbar Fusion
59
60
PROPHYLACTIC ANTIBIOTIC RATE
Similarly to knee and hip arthroplasty protocols, other spine surgeries also monitor
the prophylactic antibiotic use. As shown by the charts that follow, in 2016 we
observed prophylactic antibiotic administered up to 60 minutes before surgery in
96% of the cases; the correct prophylactic antibiotic was administered in 100% of
the cases, and 98% of them had the medication interrupted within 48 hours after
the procedure.
INFECTION RATE
We manage all patients who are admitted with spine diseases. The patients
submitted to surgical interventions are monitored during the entire time, for early
detection of suspected infections. In 2016, the infection rate in spinal surgery at
Einstein was 0.4%, a much lower rate than the international benchmark, which
ranges from 1.9% to 13.8%2.1
2. Cizik AM, Lee MJ, Martin BI, et al. Using the spine surgical invasiveness index to identify risk of surgical site infection: a multivariate analysis. J Bone Joint Surg Am. 2012;94(4):335-42.
Rate of antibiotic up to 60 min before surgical incision
– Spine Program
Rate of correct antibiotic prophylaxis – Spine Program
Rate of antibiotic prophylaxis interruption within 48 hours
– Spine Program
2011
2011
2011
63%
100%
94%
2012
2012
2012
98%
99%
93%
2013
2013
2013
97%
100%
91%
2014
2014
2014
92%
100%
92%
2015
2015
2015
94%
100%
95%
2016
2016
2016
96%
100%
98%
Infection Rate – Spine Program
2011
0.0%
2012
1.5%
2013 2014
1.2%
0.7%
2015
0.5%
2016
0.4%
61
62
OUTCOMES OF PATIENTS IN THE SPINE PROGRAM
We monitor the progression of patients with lumbar or cervical spine diseases
that have undergone surgical or conservative treatment at Einstein using specific
questionnaires that are internationally validated. For lumbar diseases, we use
Roland-Morris questionnaire; for patients with cervical spine diseases, we use
the Neck Disability Index. In addition to these specific questionnaires, we apply
the Visual Analog Scale (VAS) to all patients, which helps us measure their pain
intensity, and EuroQol, which assesses quality of life.
The questionnaire is applied by nurses and physical therapists on the first day of
intervention (surgery or physical therapy). The first questionnaire is used as the
baseline (pre-procedure questionnaire) and after the intervention, the Outcomes
Center contacts the patients 30, 90 days and 6, 12, 18, 24 and 36 months after
the procedure, using the same questionnaires, to assess the patients’ progress
concerning quality of life, pain and spinal function.
If, at any time, the patient reports worsening of the clinical presentation, the
Orthopedics Program will call the patient to the unit to carry on with management,
regardless of being rehabilitation or surgery. There is also general education about
posture and daily living habits, such as physical exercises and appropriate nutrition.
OUTCOMES OF PATIENTS AFTER LUMBAR SPINE SURGICAL TREATMENT
Visual analog scale (VAS)
The chart shows that our patients presented pain intensity grade 8 before the
intervention and progressed to 4 after surgery. In other words, pain has been reduced
by half.
Roland Morris Questionnaire
It is a questionnaire that measures physical disability self-reported by patients with
spinal pain. It comprises 24 questions scored 0 to 1 (Yes and No). The final scores
may range from 9 (no disability) to 24 points (severe disability).
The chart below shows that, before surgery, Einstein patients presented on average
15 points. After treatment, they improved gradually their lumbar function, reaching
on average 3 points, which indicates a very significant clinical evolution.
Utility – EuroQol
This questionnaire, as mentioned before, includes items related to mobility, autonomy,
ability to carry daily living activities, pain/ discomfort and anxiety/ depression. The
chart below shows significant improvement of quality of life.
Pain Scale (VAS)
(Ranging from 0 to 10, being 0 no pain and 10 worst pain)
Functional Scale (Roland Morris)
(Ranging from 0 to 24, being 0 normal function and 24 dysfunction)
Quality of Life (EQ-5D)
(Ranging from 0 to 1, being 0 inappropriate quality of life and 1 appropriate quality of life)
30 days
30 days
15.05
0.38
8.1
6.39
0.613.7
90 days
90 days
5.71
0.68
3.4
6 months
6 months
12 months
12 months
5.83
0.69
3.6
5.26
0.7
3.7
18 months
18 months
4.23
0.79
4.2
24 months
24 months
3.04
0.84
4.3
30 days 90 days 6 months 12 months 18 months 24 monthsPre-procedure
Pre-procedure
Pre-procedure
63
64
Roland Morris Questionnaire
As described before, this is a questionnaire that measures physical disability.
Before treatment, patients presented on average 12 points. After it, they progressed
positively and presented significant clinical improvement of the lumbar function.
The quality of life improvement in non-surgically treated patients shown by the chart
above indicates that rehabilitation is still the initial treatment of choice for patients with
lumbar spine degenerative diseases.
Quality of Life (EQ-5D)
(Ranging from 0 to 1, being 0 inappropriate quality of life and 1 appropriate quality of life)
OUTCOMES OF PATIENTS AFTER CERVICAL SPINE SURGICAL TREATMENT
From the beginning of the Spine Project in May 2011 to the end of 2016, 53 patients with
cervical spine disease decided for surgical treatment at Einstein. The outcomes of these
patients are demonstrated in the charts that follow.
Visual Analog Scale (VAS) – Neck pain
There has been significant improvement after surgery.
7
4
3
4
5
4
Pain Scale (VAS)
(Ranging from 0 to 10, being 0 no pain and 10 worst pain)
OUTCOMES OF PATIENTS AFTER LUMBAR SPINE CONSERVATIVE TREATMENT
From the beginning of the Spine Project in May 2011 to the end of 2016, 445 patients
with lumbar spine diseases decided for conservative (non-surgical) treatment at
Einstein. The outcomes of these patients are demonstrated in the charts that follow.
Visual Analog Scale (VAS) – Low back pain
Pain Scale (VAS)
(Ranging from 0 to 10, being 0 no pain and 10 worst pain)
7
5 5 5 5 5
4
Functional Scale (Roland Morris)
(Ranging from 0 to 24, being 0 normal function and 24 dysfunction)
12.22
10.24 9.859.2 9.12 8.51
6.14
Utility - EuroQol
As mentioned already, this questionnaire measures quality of life.
0.48
0.80.85
0.7 0.7 0.73 0.73
Pre-procedure
30 days 90 days 6 months 12 months 18 months 24 months
30 days 90 days 6 months 12 months 18 months 24 monthsPre-procedure
30 days 90 days 6 months 12 months 18 months 24 monthsPre-procedure
30 days 90 days 6 months 12 months 18 monthsPre-procedure
65
66
Utility - EuroQol
The chart above shows that there has been significant improvement in quality of life
12 months after the procedure.
Quality of Life (EQ-5D)
(Ranging from 0 to 1, being 0 inappropriate quality of life and 1 appropriate quality of life)
There has been a two-point improvement in the pain scale in the 12-month follow up,
which corresponds to clinically significant difference.
Pain Scale (VAS)
(Ranging from 0 to 10, being 0 no pain and 10 worst pain)
BETTER
BETTER
Neck Disability Index
OUTCOMES OF PATIENTS AFTER CERVICAL SPINE CONSERVATIVE TREATMENT
From the beginning of the Spine Project in May 2011 to the end of 2016, 243 patients
with cervical spine diseases decided for conservative treatment at Einstein. The
outcomes of these patients are demonstrated in the charts that follow.
Visual Analog Scale (VAS) – Neck pain
BETTER
There has been stability in the score of patients undergoing conservative treatment.
Functional Scale (Neck Disability Index)
(Ranging from 0 to 50, being 0 normal function and 50 dysfunction)
Neck Disability Index
Twelve months after the surgical treatment, patients improved 11 points in functions and
skills to carry on daily living activities.
Functional Scale (Neck Disability Index)
(Ranging from 0 to 50, being 0 normal function and 50 dysfunction)
BETTER
23
0.4
17
0.69
17
0.69
15
0.59
15
0.74
12
0.79
7
20
5
19
5
17
5
18
5
18
5
16
4
17
30 days 90 days 6 months 12 months 18 monthsPre-procedure
30 days 90 days 6 months 12 months 18 monthsPre-procedure
30 days 90 days 6 months 12 months 18 monthsPre-procedure
30 days
30 days
90 days
90 days
6 months
6 months
12 months
12 months
18 months
18 months
24 months
24 months
Pre-procedure
Pre-procedure
67
68
CRANIAL MAXILLOFACIAL PROGRAM
Following the same objectives, concepts
and the flow of the Spine Program, the
Cranial Maxillofacial Surgery Program
provides to patients a second opinion
about orthognathic, temporomandibular
joint (TMJ) and sleep apnea treatment.
The second opinion is based on the best
evidence and focused on multiprofessional
opinions of at least two surgeons of the
specialty.
As opinions are not individualized, the
indications (to surgery or conservative
treatment) are transparent and supported by the best literature evidence and
professional ethics. The project has been created to serve patients who normally
would not have access to Einstein services. Once the diagnosis and correct treatment
are defined, the patient may choose to undergo it or not. Einstein provides both
conservative and surgical treatment and patients are monitored before, during and
after the surgery.
Between February and December 2016, 687 patients were referred. Out of the total,
395 had diagnosis of temporomandibular joint dysfunction, 262 of orthognathic
surgery due to facial deformity, and 26 had sleep apnea. The program concluded the
assessment of 304 patients and the results were astonishing: 90% of the cases were
defined as non-surgical.
Patient Referrals - General
Jan/
16
0
Jul/
16
56
Feb/1
6
26
Mar
/16
85
Sep/1
6
49
Apr/
16
60
Oct
/16
43
Mai
/16
98
Nov/
16
68
Jun/1
6
78
Dec
/16
64
Aug/1
6
56
Diagnosis at Referral
Orthognathic
ATM
Sleep apnea
n=3,933
262 (38%)
395 (58%)
26 (4%)
The pilot program was run in June 2013. There were 34 patients and 17 were fully assessed.
According to Einstein assessment, 71% of the cases had no indication for surgery. The five
patients who had surgical indication were operated at Einstein. In 2014, we expanded the
scope of our services to patients with sleep apnea and temporomandibular joint diseases.
In February 2016, Einstein restarted to provide the service to patients referred by the
healthcare management companies.
There has been improvement in quality of life of patients who decided for conservative
treatment at Einstein.
Utility - EuroQol
As mentioned already, this questionnaire measures quality of life.
Quality of Life (EQ-5D)
(Ranging from 0 to 1, being 0 inappropriate quality of life and 1 appropriate quality of life)
0.46
0.62 0.660.75
0.640.60 0.58
30 days 90 days 6 months 12 months 18 months 24 monthsPre-procedure
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Definition of Einstein Management
Definition of Einstein Management - Orthognathic
Definition of Einstein Management - TMJ
Definition of Einstein Management - Apnea
Follow up of surgical cases
31 (10%)
19 (49%)
250 (98%)
4 (44%)
21 (68%)
273 (90%)
20 (51%)
6 (2%)
5 (56%)
7 (22%)
3 (10%)
Conservative Treatment
Surgical Treatment
Conservative Treatment
Surgical Treatment
Conservative Treatment
Surgical Treatment
Operated patients
Patients being prepared for surgery
Patients who refused surgery
n=304
n=39
n=256
n=9
n=31
Out of 31 patients with surgical indication, 21 were operated at Einstein and 7 were
being prepared to the surgery at the end of 2016.
INDICATION OF TREATMENT BY DISEASE
Conservative Treatment
Surgical Treatment
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Patient Experience
The strategy to place patients in the center of care and making them the key players in topics of their own interest has become an important route for improving medical and clinical practice. Patients are free to express their feelings about the experience at Einstein, using the following communication means: e-mails, social media, fax, telephone, letter or in person. Moreover, we run satisfaction surveys to measure their satisfaction levels and willingness to recommend Einstein to other people.
Year after year, the survey indicates that the promoters of Einstein brand are
far more frequent than the detractors. In 2016, Orthopedics reached 81% of
promoters, against only 3% of detractors. The performance portrays the joint
actions of the Surgical Clinical Practice, Inpatient Management, Locomotor
Program and Training area, which focused on adapting the behavioral skills and
team work practices to all professionals providing services to orthopedic patients.
In addition to these actions, Einstein has been employing other initiatives to provide
warm and humanized care. Some of the highlights are:
• Implementation of a concierge service, someone who goes to patients’ rooms to ask
about the quality of care.
• Creation of a Patient Advisory Board, which has been in existence for 4 years. Formed
by patients and family members invited by the organization, the committee meets
periodically with the directors, managers and representatives of different areas of the
organization to discuss topics related to services provided by the hospital.
813Locomotor
Values in %
17
Detractor
0 - 6
Promoter
9 - 10
Passive
7 - 8
Promoters = recommendation score equal or greater than 9 (% of respondents)
Passives = recommendation score equal to 7 and 8 (% of respondents)
Detractors = recommendation score equal or lower than 6 (% of respondents)
Question: In a scale ranging from 0 to 10, how would you score your
willingness to recommend Hospital Israelita Albert Einstein to a
friend or family member?
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• Opening of Einstein Lounge to accompanying people. The area offers many resources and information
to ensure that people are comfortable and calm.
• Because of patients’ requests and the awareness that the relationships with pets are beneficial to
patients, Einstein has created a flow to provide pet visits, according to the necessary health conditions.
All these actions are initiatives aligned with the aspiration of patients, adopted by Einstein to provide a
humanized and welcoming experience to people.
PLANETREE: CARE AND RESPECT TOWARDS PATIENTS AND FAMILY MEMBERS
Planetree is a North-American not-for-profit organization that acknowledges
healthcare organizations that are patient-centered providers, in healthy
environments and prone to cure patients. In Latin America, Einstein was the first
organization recognized by Planetree (in December 2011).
In this model, active participation of the patient and the family member is
encouraged through information and education. The partnership with the clinical
team is also encouraged, to provide a more humanized and seamless experience
of treatment.
Einstein Lounge
MAGNET RECOGNITION PROGRAM
Magnet Recognition Program was developed by ANCC
(American Nurses Credentialing Center) to acknowledge
the healthcare organizations that have nursing services of
excellence and contribute to the dissemination of successful
practices and strategies in nursing.
This program provides to consumers the best reference about the quality of
care that they can expect to receive in a health care organization. It is based on
quality indicators and best practice standards of the American Nurses Association
(ANA) and the Scope and Standards for Nurses Administrators, whose criteria
are: transformational leadership, exemplary professional practice, empowerment
structure, new knowledge, innovation and improvement, and empirical results.
Patient Satisfaction Score
2014
90 90
2015
8992
2016
88 89
General
Locomotor
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Education and Scientific Events MEDICAL RESIDENCY IN ORTHOPEDICS AND TRAUMA
The Medical Residency Program in Orthopedics and Trauma started in March 2013, after
its approval by the Ministry of Education, the National Board of Medical Residency and
Brazilian Society of Orthopedics and Trauma (SBOT). There are three seats for each of
the three regular years of the program.
The resident physicians have theory classes and take turns in eight-week internships,
dividing their time between Unit Morumbi and Hospital Municipal Dr. Moyses Deutsch
-M’Boi Mirim. In 2015, the resident physicians joined Programa Cuidar, which provides
outpatient supervised care to employees of the organization and their dependents,
comprising different areas of orthopedics (pediatric orthopedics, upper limb affections,
lower limb affections and spinal diseases).
In 2016, the second class of Orthopedics and Trauma resident physicians was
graduated. The dedication and commitment of the resident physicians and the team
involved in their training was rewarded by having all applicants of the hospital pass the
test for Specialists in Orthopedics and Trauma (TEOT 2016). In order to further deepen
knowledge and skills acquired in their areas of interest, our three resident physicians
were included in the improvement program of the organization. These programs are still
pending acknowledgement by the subspecialties’ boards in Orthopedics and Trauma.
GRADUATE STUDIES
The non-degree graduate studies in Multidisciplinary Orthopedics and the degree
graduate course in Health Sciences contribute to the dissemination of knowledge to
the orthopedic team.
The proposal of the graduate studies in Multidisciplinary Orthopedics is to prepare
and update the members of the multiprofessional team to work in treatment and
rehabilitation of the main lesions related to the locomotor system. In 2016, two more
classes completed the course, which has already trained 100 new specialists since its
beginning.
The degree graduate program in Health Sciences is comprised of one major
area, dedicated to Medical Sciences research, with research lines and projects in
basic, physiological and physiopathological studies or those related to diagnostic,
treatment and prevention aspects of communicable and non-communicable
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diseases. In orthopedics, there are three faculty members who are focused on the research line
of Aging, studying clinical and experimental aspects of aging. In 2016, two new master degree
applicants and one PhD applicant joined the program.
FORUMS
Interdisciplinary Forums of Orthopedics and Rheumatology are monthly meetings that gather
physicians from the open clinical staff and the main leaders of Einstein. The objectives of these
forums are to strengthen the ties between the Clinical Staff and the Organization, providing a
channel for free expression of opinions, criticisms and suggestions, and to treat topics of interest
in medical practice. This is all focused on improving the workplace and the provided services. In
the meetings, we also address clinical guidelines based on the best scientific evidence.
The events normally take place at lunchtime, in meeting rooms at Einstein. They are joined by
members of the Clinical Staff and representatives of the Clinical Director Office, Medical Practice
Office and Clinical Practice. In 2016, there were three meetings to discuss topics related to
orthopedics and trauma.
Key topics discussed in 2016 were:
• Pre, peri and postoperative care in orthopedic and
spine surgery
CLINICAL MEETINGS
In partnership with the Imaging/ Radiology team, the Locomotor Program carries out
weekly meetings to discuss clinical cases and relevant topics. The meeting receives
orthopedists, orthopedics and radiology resident physicians, rheumatologists,
radiologists and physiatrists, to encourage the production of future scientific projects
and continuing medical education.
• Osteoporosis – care with
the vertebral spine
• Postoperative pain
management in children
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TRAINING SESSIONS
• Training on Hip and Knee Managed Protocols
The purpose of the session was to update the multiprofessional teams in areas of general medicine
and severely-ill patients when caring for patients submitted to hip or knee arthroplasty. The training
program was directed to standardizing patient care, creating a specific team to provide care to severe
patients.
• Home Care Project Training
To better serve our clients submitted to knee and hip arthroplasty, we have trained the teams of Home
Care, which make home visits before and after the surgery. The objective was to prepare the team to
provide specific care and make residential adaptations.
• Training on preventing orthopedic infections
The training program was focused on giving a preoperative bath of chlorhexidine at home and using
intra-hospital CHG-soaked towels to prevent surgical site infections in orthopedic patients.
SPINE BOARD
Every week, orthopedists, neurosurgeons and the multidisciplinary team gather for the Spine Board
to discuss cases referred to the Spine Project. The team of Radiology supports the discussions and
clarifies the questions. The meeting is opened to the whole Clinical Staff and it is based on exchange of
experiences, trying to identify the best approach for each patient.
XVI EXPOSIÇÃO DA QUALIDADE E SEGURANCA 2016 (QUALITY AND SAFETY EXHIBIT)The Quality and Safety Exhibit is an annual event that promotes exchange of
experiences among the different areas of the organization, opening opportunities to
adopt continuous improvement practices and to disseminate to internal and external
clients what the areas do.
The Orthopedics Program submitted two papers in 2016:
• Bacterial resistance prevention by interrupting prophylactic antibiotic within 24
hours in managed orthopedic surgeries (Magnet category);
• Experience of Spine Project (Planetree category).
COURSES
• 1º Diálogos entre a Pediatria e a
Ortopedia Pediátrica (1st Forum of
Pediatrics and Pediatric Orthopedics)
Held on July 16, 2016, at Auditorium
Kleinberger, at Einstein. The event
addressed osteoarticular infection,
equine gait, lower limb pain, newborn
hip and postoperative pain. The target
audience included orthopedists,
pediatricians, anesthesiologists,
physiatrists and multiprofessional team
members (physical therapists, physical
educators, pharmacists and nurses).
• 1º Simpósio de Coluna (1st Spine Symposium)
Held on August 5-6, 2016, the event focused on degenerative diseases of the
lumbar spine, approached by multidisciplinary and multiprofessional clinical case
discussions with the specialists and the audience, also counting on the presence of
Edward Covington, from Cleveland Clinic.
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Research and Scientific Production
RESULTS OF SCIENTIFIC ACTIVITY AT EINSTEIN ORTHOPEDICS
In 2016, the Orthopedics staff participated in the following projects:
• 20 research projects submitted to the Research Project Management System
(SGPP – Sistema de Gerenciamento de Projeto de Pesquisa);
• 16 approved research projects;
• 10 completed research projects;
• 33 ongoing research projects.
PUBLICATION IN SCIENTIFIC JOURNALS
In 2016, there were 25 studies on orthopedics published, ten of them in journals with
impact factor > 1 (IF>1). These numbers represent a relevant increase compared
to previous years. The complete list of publications from 2016 can be access on
the internet at: http://www.einstein.br/especialidades/ortopedia/ensino-pesquisa/
publicacoes-cientificas.
The table below represents the scientific production of the Orthopedics area:
Evolution of Research Projects
11
15 16 16
22
33
7
1310
14
2320
Submitted Approved Ongoing Completed
2014 2015 2016
IF 2012 2013 2014 2015 2016 Total
>5 2 0 2 2 4 10
>1 and < 5 7 3 6 10 10 36
<1 0 2 3 0 1 6
No IF 6 10 4 7 10 37
Total 15 15 15 19 25 89
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NATIONAL AND INTERNATIONAL FUNDING
The Locomotor Program has created a scientific structure that has provided more
funding opportunities.
In 2016, there were two projects funded by Fundação de Amparo a Pesquisa do Estado
de São Paulo (Fapesp – Research Funding Institution for the State of Sao Paulo),
amounting to approximately R$800,000.
Einstein has also taken part in a special funding process by Fapesp and Instituto de
Estudos de Saude Suplementar (IESS – Private Health Study Institute) that selected
four research projects on Sustainability of Private Healthcare Sector. One of them
was Einstein project – Second opinion of spine surgical indications: cost-effectiveness
assessment. The project is carried out by the area of orthopedics, supported by the
Rehabilitation Center.
2013
2013
2
152,740.00
2014
2014
1
209,740.00
2015
2015
1
237,987.50
2016
2016
2
571,019.56
Total funded projects (overall)
Total funded amount (overall)Publications by Impact Factor
>5
<1 and > 5
einstein (Sao Paulo)
<1
No IF
2014
313
6
2
2015
250
10
2
2016
7
31
10
4
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Concerning international funding, a funded project of approximately R$150,000 as a
partnership between Fapesp and Ohio University has also been approved.
RESEARCH LINES
Research lines may be represented as specific topics, which gather projects whose results are
closely related. The scientific production of Einstein Orthopedics has adopted the research
line “Aging”, comprising investigations in four major areas:
• Cell therapy – experimental studies;
• Managed protocols of the Orthopedics Program;
• Evidence-based Orthopedics and Rheumatology;
• Bone tumors: Early imaging diagnosis.
2013
1
0 0
1
0 0
2014 2015
1
2016
1
Total submitted x approved projects (international funding)
Submitted
Approved
2013
45,000.00 45,000.00
0.00
2014 2015 2016
147,001.50
Funded Amount (international)
As to Cell Therapy, there are the following ongoing projects:
1. ALTERNATIVE THERAPIES FOR CARTILAGE REPAIR: IN VITRO STUDIES
Team: Eliane Antonioli, Felipe B. D. de Oliveira, Anna Carla Goldberg, Mario Ferretti
External collaborator: Helena B. Nader (Full Professor of Unifesp and Director of the
Brazilian Society for Progress of Science - Sociedade Brasileira para o Progresso da
Ciência). Funding: Fapesp #2012/00831-7 – PI: Mario Ferretti
2. APPLICATION OF PCL/ CNT NANOFIBERS ALIGNED IN DIFFERENT ORIENTATIONS
AS FRAMEWORK FOR MENISCAL REGENERATION
Team: Eliane Antonioli, Felipe B. D. de Oliveira, Mario Ferretti Filho
External collaborators: Anderson de Oliveira Lobo (Coordinator, Laboratorio de
Nanotecnologia Biomedica – Laboratory of Biomedical Nanotechnology /Instituto de
Pesquisa e Desenvolvimento - Universidade do Vale do Paraiba), Thiago Domingues
Stocco (Ongoing PhD. Student , Engenharia Biomedica, UNIVAP).
3. ANALYSIS OF CELL AGING IN MESENCHYMAL STEM CELLS (REPLICATIVE
SENESCENCE) AND ITS APPLICABILITY IN CELL THERAPY
Team: Eliane Antonioli, Andrea Sertié, Carla Piccinato, Natalia Torres, Mario Ferretti
4. IN VITRO ANALYSIS OF THE CHRONDROPROTECTIVE ACTION OF LOSAC AND
LOPAP MOLECULES
Team: Eliane Antonioli, Edgard S. Pereira Junior, Moises Cohen, Mario Ferretti
External collaborators: Dr. Ana Marisa Chudzinski-Tavassi (Coordinator of Laboratório
de Inovação e Desenvolvimento no Instituto Butantan – Laboratory of Innovation and
Development), Miryam P. A. Flores (researcher, Instituto Butantan).
5. RESPONSE OF OSTEOARTHRITIS BIOMARKERS AFTER A REHABILITATION PROGRAM
– PARTNERSHIP WITH OHIO STATE UNIVERSITY (OSU)
Team: Eliane Antonioli, Felipe B. D. de Oliveira, Sudha Agarwal, Mario Ferretti
Funding: Fapesp #2015/50274-5 PI: Mario Ferretti
6. REGENERATIVE CAPACITY OF MESENCHYMAL CELLS ADMINISTERED LOCALLY AND
SYSTEMATICALLY IN OSTEOPOROSIS ANIMAL MODEL
Team: Eliane Antonioli, Felipe B. D. de Oliveira, Mario Ferretti
Funding: Fapesp #2015/16606-0 PI: Mario Ferretti
7. SECOND OPINION IN INDICATIONS OF SPINE SURGERY: COST-EFFECTIVENESS
ASSESSMENT
Team: Mario Lenza, Miguel Cendoroglo Neto, Eliane Antonioli, Mario Ferretti
External collaborators: Wilson Mello Alves Junior, Rodrigo A. Vasconcelos,
Leonardo Oliveira Pena Costa, Paulo Portes Teixeira Funding: Fapesp #2015/50352-6
PI: Mario Ferretti
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Social Responsibility Opened in April 2008, the hospital resulted from a long time request of the local population
and provides support and strengthens the primary healthcare system of the region M’Boi
Mirim, including the districts of Jardim Angela and Jardim Sao Luiz, which add up to 600,000
inhabitants. Operating as a reference to 43 primary healthcare centers (31 UBSs, 9 AMAs,
2 Specialty AMAs and 1 specialty outpatient unit), the Hospital is primarily focused on
urgencies, emergencies and deliveries.
In 2013, when Einstein started its medical residency program in Orthopedics and Trauma,
Hospital Municipal M´Boi Mirim was chosen to be a partner in the training and development
of resident physicians.
To present, seven resident physicians are part of the team of orthopedists credentialed by
Sociedade Brasileira de Ortopedia e Traumatologia (SBOT). There they learn about the
Universal Public Healthcare System (SUS) care and can study, discuss and follow up different
cases of orthopedic emergencies.
The first, second and third year residents rotate in their internships every two months, but
throughout the year they all maintain contact with the municipal hospital, working on night
and weekend ED shifts.
Part of their training includes workshops with partnering organizations about synthetic bone,
bringing better clinical practice to the population at M’Boi Mirim.
ORTHOPEDICS INDICATORS FOR HOSPITAL MUNICIPAL DR MOYSES DEUTSCH (M’BOI MIRIM)
The Locomotor Program is engaged in two important social
responsibility actions.
One of them is orthopedic care provided to patients in the Organ
Transplant Program (liver and kidney). Some patients may present
orthopedic complications such as pyoarthritis, osteomyelitis and
skin infections which, in most cases, require surgeries.
Another social responsibility action of the program is orthopedic
care provided at Hospital Municipal Dr. Moyses Deutsch - M’Boi
Mirim, which is administered by Einstein.
Number of Orthopedic Outpatient Visits
1st sem 2014
3,494 4,534
2nd sem 2014
3,8975,323
1st sem 2015
3,4485,507
2nd sem 2015
3,710
7,581
1st sem 2016
4,067
16,199
2nd sem 2016
4,386
17,085
Orthopedic Visits
Total Visits
One of the highlights of the social activities
of Einstein orthopedics is
service provision at Hospital Municipal
do M’Boi Mirim. In 2016, the orthopedics at Hospital M’Boi Mirim totaled 8,453 outpatient orthopedic
visits, which amounts to 25% of the entire volume of outpatient visits.
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Brand Dissemination and Management
Through its website, which brings detailed information about the specialty activities, and media coverage in different channels, Orthopedics used communication as an instrument to disseminate information to the public and strengthen Einstein brand.
INSTITUTIONAL WEBSITE
In 2016, the new institutional website was launched. It has led to a drop in number of
visits due to three main reasons:
• Previous content, which was over two years old, did not migrate to the new version;
• Separation between the Teaching website and the main portal;
• Expected decrease in visits due to the inclusion of new Google pages.
In 2016, Orthopedics had fewer visits to the website than in 2015. Despite that, over
110,000 people visited it and the number of pageviews per visit increased compared
to the two previous years (2.3 pages per visit as opposed to 1.2 in 2015).
MEDIA PARTICIPATION
Considering printed media, radio and TV, the Orthopedics area stood out in over 40
coverages throughout 2016.
Number of visits
436,731
600,981
113,905
Number of pageviews
617,754723,977
260,504
Institutional website
2014
2015
2016
2014 2015 2016
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114
44
Media appearance
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LOCOMOTOR PROGRAM
Dr. Mario Ferretti Filho
Medical Manager
+55(11) 2151-1444
Dr. Mario Lenza
Medical Coordinator
+55(11) 2151-1444
Dr. Rodrigo Junqueira Nicolau
Physician
+55(11) 2151-1444
Dr. Eliane Antonioli
Researcher I
+55(11) 2151-2265
Isabela Dias Paião
Nurse
+55(11) 2151-1443
Luciana Pereira de Magalhães
Machado
Nurse
+55(11) 2151-5248
Renata Alves Lima
Administrative Technical Assistant
+55(11) 2151-4585
Gerusa Leandro de Souza Silva
Administrative Technical Assistant
+55(11) 2151-5249
Thais Rosa de Oliveira
Conceição
Administrative Technical Assistant
+55(11) 2151-3045
Vanuza de Oliveira Silva
Administrative Technical Assistant
+55(11) 2151-4586
Staff and Contact InformationREHABILITATION CENTER
+55(11) 2151-1100
ORTHOPEDIC RADIOLOGY
+55(11) 2151-2487
INPATIENT UNIT – 11TH FLOOR
ORTHOPEDICS
+55(11) 2151-1168
MEDICAL OFFICES BUILDING A1
+55(11) 2151-1233
EMERGENCY DEPARTMENT UNIT
+55(11) 2151-1233
HOME CARE
+55(11) 2151-2944
ORTHOPEDIC MEDICAL RESIDENCY
PROGRAM
Dr. Mario Ferretti Filho
Supervisor, Orthopedics and Trauma
Medical Residency Program
+55(11) 2151-1444
Dr. Mario Lenza
Coordinator, Orthopedics and Trauma
Medical Residency Program
+55(11) 2151-1444
Dr. Francesco Camara Blumetti
Physician Preceptor of Orthopedics and
Trauma Medical Residency Program
+55(11) 2151-1444
Dr. Luiz Fabiano Taniguchi
Coordinator of the Orthopedic team at
Hospital do M’Boi Mirim
Physician Preceptor of Orthopedics and
Trauma Medical Residency Program
+55(11) 2151-1444
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