Shared care (comanagement) | Revista Clínica Española

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Rodríguez Esteban, L. Carballo Arzola, S. Miranda Montero, M. Farrais Villalba, J.A. Medina García, J. Ode Febles" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Rodríguez Esteban" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Carballo Arzola" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Miranda Montero" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Farrais Villalba" ] 4 => array:2 [ "nombre" => "J.A." "apellidos" => "Medina García" ] 5 => array:2 [ "nombre" => "J." "apellidos" => "Ode Febles" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S001425651500199X" "doi" => "10.1016/j.rce.2015.07.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S001425651500199X?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887415000910?idApp=WRCEE" "url" => "/22548874/0000021600000001/v1_201601280010/S2254887415000910/v1_201601280010/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Special article" "titulo" => "Shared care (comanagement)" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "27" "paginaFinal" => "33" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "E. Montero Ruiz" "autores" => array:2 [ 0 => array:3 [ "nombre" => "E." "apellidos" => "Montero Ruiz" "email" => array:1 [ 0 => "eduardo.montero@salud.madrid.org" ] ] 1 => array:1 [ "colaborador" => "por el Grupo de Trabajo de Asistencia Compartida e Interconsultas de la Sociedad Española de Medicina Interna (SEMI)" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Asistencia compartida (comanagement)" ] ] "textoCompleto" => "In terms of the support that medical services provide surgery departments, we should be very aware that these services have very specific local and individual characteristics. Each hospital has their own unique structure, equipment and operation, even when compared to theoretically similar centers. Within the same hospital, the various medical and surgery departments are very different one from another in terms of the approach and organization for this type of healthcare activity. The same can be said of the physicians involved in this activity, even in the same department, with completely different behaviors and work styles in many cases. The support should therefore be analyzed and executed from an individual perspective, and the general information and available literature should be assessed and adapted to each specific context. We should keep in mind that to perform the safest work for our patients and for ourselves we might need to let go of traditions and autonomy that some practitioners believe, erroneously, are necessary to conduct their work effectively and pleasantly.<a class="elsevierStyleCrossRef" href="#bib0290">1</a>We present this document as a position statement of the Shared Care and Interconsultations Workgroup of the Spanish Society of Internal Medicine on the relevant concepts and issues of a special form of medical support for surgery departments, which entails a profound change in the organization of the hospital medical care: shared care (comanagement).Characteristics of hospitalized surgical patientsThe evolution of surgical and anesthetic techniques and procedures has enabled operations for increasingly older patients with greater comorbidity. Moreover, the development of outpatient surgery with short stays has resulted in many surgical patients not requiring hospital admission, or only needing admission for a brief period. One of the consequences of these developments is that patients hospitalized in surgery departments are increasingly older and, in particular, have increasingly more comorbidity.<a class="elsevierStyleCrossRefs" href="#bib0295">2,3</a> It is estimated that at least 60% of surgical patients have significant medical comorbidities, with an even greater prevalence in the elderly.<a class="elsevierStyleCrossRef" href="#bib0305">4</a>Comorbidity due to acute or chronic diseases increases hospital mortality, stays, costs and readmissions.<a class="elsevierStyleCrossRef" href="#bib0310">5</a> For the last 60 years, it has been known that comorbidity is especially significant in the surgical area because comorbidity is the origin of more than 80% of postoperative deaths.<a class="elsevierStyleCrossRef" href="#bib0315">6</a> In elderly patients, comorbidity is even more influential than age in terms of the outcome of surgery.<a class="elsevierStyleCrossRef" href="#bib0320">7</a> Postsurgical complications are much more important than the preoperative risk in postoperative survival,<a class="elsevierStyleCrossRef" href="#bib0325">8</a> but even more important is the delay in diagnosing and treating these complications.<a class="elsevierStyleCrossRefs" href="#bib0330">9,10</a> A 100% increase is expected in the onset of complications in surgical patients in the next 2 decades.<a class="elsevierStyleCrossRef" href="#bib0340">11</a>An issue to consider with patients hospitalized in surgery departments is that there is a significant percentage of these patients who, for various reasons, do not undergo operations. This percentage is different in each specialty surgical. This percentage reaches 23% in a number of series<a class="elsevierStyleCrossRef" href="#bib0345">12</a> and 46% for patients in general surgery for whom an interconsultation with internal medicine is requested.<a class="elsevierStyleCrossRef" href="#bib0350">13</a> These percentages are significant because the surgeons have special difficulties in providing care for this patient group.<a class="elsevierStyleCrossRefs" href="#bib0345">12,14</a>Challenges and problems of surgery departmentsAt present, surgery departments face a number of challenges and problems that hinder their activity and increase the need for medical support:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Age and comorbidity of their patients. Aspects already mentioned above.</li><li class="elsevierStyleListItem" id="lsti0010">•Medical training. Training provided to residents in general and to those of the surgical area in particular is increasingly specialized, with less general medical knowledge. When working as surgeons, residents (in most cases) are dedicated to specific areas of their specialty, further narrowing the field of their competencies and skills, which increases the difficulties when providing care for their hospitalized patients.</li><li class="elsevierStyleListItem" id="lsti0015">•Healthcare organization. In general, surgery departments have a healthcare organization that greatly impedes the daily follow-up of their patients, by frequently switching the surgeon who visits the patient, in many cases switching on a daily basis. This problem with following-up a patient's clinical evolution is especially relevant in the case of medical diseases. Furthermore, this organization dilutes responsibility for the patient, promotes errors and greatly impedes communication.<a class="elsevierStyleCrossRef" href="#bib0360">15</a> The daily change in the surgeons who make the rounds increases the hospital stay and slows decision making.<a class="elsevierStyleCrossRef" href="#bib0365">16</a></li><li class="elsevierStyleListItem" id="lsti0020">•Political-healthcare pressure. The pressure caused by waiting lists is unbalancing the surgery departments. The weight of the surgical act with respect to other departmental activities is disproportionate. Surgeons are increasingly being directed to only consider whether to operate and when, leaving the other considerations in second place.</li></ul>Increased need for collaborationAs a result of the facts and circumstances mentioned above, there is an increasing need for general practitioners during surgery hospitalizations.<a class="elsevierStyleCrossRef" href="#bib0370">17</a> Additionally, the more specialized the physician, the more interconsultations are requested.<a class="elsevierStyleCrossRef" href="#bib0375">18</a> This increased need for collaboration is manifested by the increased number of interconsultations requested of the medical area by surgery departments, which creates a high risk of subjecting the patient to a “circus of consultants”.<a class="elsevierStyleCrossRef" href="#bib0380">19</a> This increase in the number of requests for interconsultations is especially intense for internal medicine. In fact, between 2000 and 2007, the number of interconsultations requested of this department by surgery units increased 60%.<a class="elsevierStyleCrossRef" href="#bib0295">2</a>InterconsultationThe interconsultation represents the standard system of healthcare collaboration among the various hospital departments: requesting another physician to provide their opinion concerning the diagnosis, the regimen to follow and the treatment or to assume direct responsibility for one of the patient's specific problems.<a class="elsevierStyleCrossRef" href="#bib0385">20</a> Although the actual volume remains unknown, an approximate calculation estimated that the Spanish departments of internal medicine received more than 111,000 interconsultation requests from the surgery area in 2006.<a class="elsevierStyleCrossRef" href="#bib0390">21</a> However, medical interconsultations suffer from numerous problems in the implementation mechanism,<a class="elsevierStyleCrossRef" href="#bib0390">21</a> the delimiting or transferring of responsibility for the patient,<a class="elsevierStyleCrossRef" href="#bib0390">21</a> the transmission of information,<a class="elsevierStyleCrossRefs" href="#bib0395">22,23</a> the call/rejection effect on the consultants<a class="elsevierStyleCrossRef" href="#bib0295">2</a> and applicants,<a class="elsevierStyleCrossRef" href="#bib0405">24</a> the seasonal nature of requests,<a class="elsevierStyleCrossRef" href="#bib0295">2</a> the urgency of interconsultations,<a class="elsevierStyleCrossRefs" href="#bib0410">25,26</a> the unjustified repetitions<a class="elsevierStyleCrossRefs" href="#bib0410">25–27</a> and the delays in their request.<a class="elsevierStyleCrossRefs" href="#bib0415">26,28</a> For these and other reasons, interconsultations have for years been known to be expensive<a class="elsevierStyleCrossRef" href="#bib0435">30</a> and rarely effective,<a class="elsevierStyleCrossRef" href="#bib0430">29</a> statements that have yet to be contradicted.Shared careThe pressure exerted by surgery departments on the medical area and the deficient response by the interconsultation system have led to the development in the last few years of a new healthcare organization model: shared care. This model is a method for organizing and improving the medical care of patients hospitalized in surgery departments, in which 2 different specialists share a patient's medical care. It is defined as shared responsibility and authority in the handling of a hospitalized patient.<a class="elsevierStyleCrossRef" href="#bib0385">20</a> The physician specialist takes charge of the patient's medical problems (pre-existing or newly diagnosed), from the patient's admission to the surgery department to their hospital discharge, without needing to be consulted.<a class="elsevierStyleCrossRef" href="#bib0385">20</a> Although shared care and interconsultations are medical support systems for surgery departments, these methods have significant differences (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). This form of healthcare organization reduces the surgical specialist's concern about not diagnosing serious medical problems, provides them time to focus on the specific aspects of their sphere of action and reduces legal risks.<a class="elsevierStyleCrossRef" href="#bib0440">31</a> Shared care is showing its efficacy in Spain<a class="elsevierStyleCrossRef" href="#bib0355">14</a> and beyond.<a class="elsevierStyleCrossRef" href="#bib0445">32</a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">•Perioperative medicine is shared care focused exclusively on the perioperative period.<a class="elsevierStyleCrossRef" href="#bib0450">33</a> Although there is no one universally accepted definition, even for establishing the so-called perioperative period, perioperative medicine is understood to cover all medical activity related to the surgical process. Its purpose is to achieve the best conditions for the patient at the time of the surgery, that the surgery is performed as safely and effectively as possible and that the fewest possible postoperative complications arise.<a class="elsevierStyleCrossRef" href="#bib0450">33</a></li></ul><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Patients eligible for shared careA frequent question is whether shared care should extend to all hospitalized patients in a surgery department, regardless of their condition and medical history or to just certain groups. For the latter case, a simple and automatic selection system should be used. However, there are no sufficiently safe and easy systems for implementation. Some of the criteria employed include:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030">•Age. An important criterion that is easy to apply but does not differentiate the risk or the postsurgery prognosis well. For this, comorbidity, medical history and type of surgery are more important than age.<a class="elsevierStyleCrossRefs" href="#bib0455">34,35</a> Many high-risk patients who should receive shared care would be below our established cutoff age.</li><li class="elsevierStyleListItem" id="lsti0035">•Type of hospitalization (emergency/scheduled). Simple application criterion. In principle, it is easy to understand that emergency patients would benefit the most, given that they are at greater risk, and that unscheduled patients have lower risk, are clinically stable and have already been assessed in the preanesthesia visit. However, this is not a good criterion. For example, which patient would benefit more from shared care: a 25-year-old man with no medical history who is admitted for acute appendicitis or a 60-year-old patient with a history of diabetes mellitus, arterial hypertension, obesity, and myocardial infarction a year ago and who is admitted for scheduled surgery for colon cancer?</li><li class="elsevierStyleListItem" id="lsti0040">•Type of patient (operated/not operated). In the surgery departments, between 8% and 23% of hospitalized patients do not, for various reasons, undergo operations: their disease does not require surgery at that time, their disease requires surgery but the patient is in no condition to be operated on or the patient is admitted for diagnostic tests.<a class="elsevierStyleCrossRef" href="#bib0345">12</a> If we only treat patients with surgery (perioperative medicine), those patients who do not undergo surgery will not receive shared care. However, surgeons have more problems in managing and following up patients who do not undergo surgery.<a class="elsevierStyleCrossRef" href="#bib0345">12</a> These patients would therefore be eligible for shared care.</li><li class="elsevierStyleListItem" id="lsti0045">•Disease. In this case, patients are selected by their medical condition (e.g., hip fractures). Although the results for these patients would be excellent, a large number of the patients who could benefit from shared care would be excluded due to the highly selective process.<a class="elsevierStyleCrossRef" href="#bib0465">36</a></li><li class="elsevierStyleListItem" id="lsti0050">•At the request of the surgical specialist. This is the classical care model to apply in cases where there is no automatic selection system. Operating on an on-demand system has many of the problems presented by classical interconsultations that we mentioned earlier.</li></ul>In addition to the lack of an effective and easy patient selection mechanism, there is evidence that at least 90% of patients hospitalized in surgery departments would benefit from shared care.<a class="elsevierStyleCrossRef" href="#bib0470">37</a> Therefore, all patients admitted to surgery departments should be considered eligible for shared care. Assessing all patients at admission does not mean that the intensity applied to the follow-up will be the same. This will depend on each patient.Who should provide the shared care?There have been experiments in shared care conducted by physicians of various medical specialties. If we select a certain patient group and they receive treatment from the corresponding specialist, good results are expected. The broadest collaboration of this type is shared care with internists<a class="elsevierStyleCrossRef" href="#bib0475">38</a> and geriatricians<a class="elsevierStyleCrossRef" href="#bib0480">39</a> for hip fractures, although there are lesser known examples such as assigning nephrologists to intensive care units.<a class="elsevierStyleCrossRef" href="#bib0485">40</a> However, these and other experiments are directed to a disease or group of diseases and are not patient focused. Therefore, given the type of patients admitted to hospitals, the most likely scenario is the need to involve several specialists in the patient's care.The simultaneous or consecutive actions of various specialties for a patient can cause numerous problems.<a class="elsevierStyleCrossRef" href="#bib0490">41</a> The care can be redundant, inefficient, problematic and unsafe for the patients due to poor coordination and integration,<a class="elsevierStyleCrossRef" href="#bib0495">42</a> causing problems of polypharmacy, test duplication, confusing and even conflicting medical comments or indications, among others.<a class="elsevierStyleCrossRef" href="#bib0500">43</a> The number of specialties that provide care for the patient is associated with an increased risk of adverse events and inadequate care.<a class="elsevierStyleCrossRef" href="#bib0490">41</a> Even “excessive” specialization can be harmful, given that medical errors can result from the specialization itself.<a class="elsevierStyleCrossRef" href="#bib0505">44</a> Possibly due to these reasons, the internist has for decades been the specialist physician most required by surgery departments, due to the internist's versatility and ability.<a class="elsevierStyleCrossRef" href="#bib0510">45</a> More than 90% of perioperative interconsultations are resolved by internists.<a class="elsevierStyleCrossRef" href="#bib0515">46</a> General practitioners also have better results than specialists in resolving the interconsultations.<a class="elsevierStyleCrossRef" href="#bib0520">47</a> Internal medicine is therefore the most appropriate specialty for shared care. Due to their overall patient-focused (not disease-focused) view, internal medicine has the most experience in this type of collaboration among departments. Internal medicine departments also consider this need in their teaching programs<a class="elsevierStyleCrossRef" href="#bib0525">48</a> and in the strategic objectives of the Spanish Society of Internal Medicine.<a class="elsevierStyleCrossRef" href="#bib0530">49</a>Although internists who work in a surgery department can be completely independent of the department of internal medicine, it is advisable that they maintain an organic dependence on the latter. It is very important to have a good relationship with the department because their collaboration is needed in the support they can provide other staff members and, of course, in the transfers from the surgery departments to internal medicine. This is applicable to related activities, such as interconsultations.Internist characteristicsThe first thing an internist who works in a surgery department should know is what the surgeons and anesthesiologists want and do not want from the internist:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055">•What do surgeons and anesthesiologists want? The ability to operate on the patient as soon as possible and under the best possible conditions and that the postoperative period proceeds rapidly and without complications. For patients who do not undergo an operation for whatever reason, the surgeons’ main interest centers on discharging the patients. What they expect from the internist is empathy and assistance in achieving these objectives, which focus only on the relevant issues for surgery, leaving other issues that could be assessed.<a class="elsevierStyleCrossRef" href="#bib0535">50</a></li><li class="elsevierStyleListItem" id="lsti0060">•What do surgeons and anesthesiologists not want? They do not want to be told how and when to do their job; a lack of respect for their method of thinking and working; little motivation on the part of the internist; a lack of focus on the issues that are important to them; and an internist who is an obstacle or a drag on their daily activity.</li></ul>The internist should encompass a number of specific qualities and characteristics in order to properly conduct this activity:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0065">•Work style. Hospital medical specialists are likely to be more individualistic. They are accustomed to making decisions alone, only consulting when they feel it is necessary. They also delve into all of the healthcare aspects that could be involved in the patient, without focusing exclusively “on their parcel” or the reason for the consultation or hospitalization. The internist who works in surgery departments must change these characteristics and priorities. The internist must work in a team with other workmates and must subordinate themselves to their workmate on some issues, given that the latter is the one who must make the most important decisions. Furthermore, the internist should focus only on that which interests the surgeon, relegating the other activities and diagnoses for later or for an external consultation. In this work team, we should not forget the anesthesiologist.</li><li class="elsevierStyleListItem" id="lsti0070">•Personal qualities. The internist assigned to a surgery department will be trained, capable of working in a team and adaptable, given that each department is different. Furthermore, internists should have an open mind and be decisive and pragmatic. Excessively thorough and meticulous individuals will not adapt well to this work environment.</li><li class="elsevierStyleListItem" id="lsti0075">•Extensive responsibility for the patient. The internist will work in the same manner as in the internal medicine rooms, making decisions, requesting tests and prescribing treatments, with the only condition of coordinating with the surgeon and ensuring the least possible hindrance to the surgeon's dynamic.</li><li class="elsevierStyleListItem" id="lsti0080">•Without restriction “by specialty”. The internist should act as such in the broadest sense, where none of the patient's problems are foreign to the internist. The internist has the ability to intervene in almost all situations that can occur with the patient. If the internist believes that the analgesia is insufficient, they should correct the anesthesiologist. Similarly, if there appears to be a surgical wound infection, the internist should tell the surgeon. The internist cannot say “it is responsibility of others” and look away. The internist's purpose is the patient and then the surgeon.</li></ul>Concerns to overcomeThe start of shared care with internists in a surgery department entails a number of doubts and concerns by the surgeon and anesthesiologists, which must be given significant consideration:<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0085">•They do not replace the surgeons and anesthesiologists. Having internists in the surgery ward does not mean that the surgeons and anesthesiologists are replaced. Each will continue with their tasks, without having to worry about processes for which they are not well qualified. For the same reason, obligations for which the internists are not sufficiently qualified cannot be shifted to them.</li><li class="elsevierStyleListItem" id="lsti0090">•Key decisions. In a surgery department, the main decisions are whether the patient should be admitted, whether they have a surgical indication, whether they are in a condition to undergo an operation or whether they should be discharged. These decisions are to be made by the surgeons and anesthesiologists. The internist, in every case, can help with some of these decisions.</li><li class="elsevierStyleListItem" id="lsti0095">•Consensus. There is the ingrained idea that the internist, due to their knowledge and individualism, makes decisions without taking into account the surgeons and anesthesiologists. All activity conducted by the internist, especially that which interferes with the surgeons and anesthesiologists, should be agreed upon beforehand.</li><li class="elsevierStyleListItem" id="lsti0100">•Extending the hospitalization. There is a deep-seated fear that the internist will request tests or start treatments that extend the hospitalization beyond what is strictly necessary for the surgical process. This should not be the case. Tests and treatments will be indicated without interfering with this process. If the surgical problem has been resolved, the patient should leave the surgery department. If in the condition to do so, the patient will be discharged, although they will be referred to internal medicine for consultation. If not, the patient will be transferred to the department of internal medicine.</li></ul>Work setting studyThe implementation of shared care in a specific hospital department requires a deep understanding of its conditions and situation in order to plan for its needs and subsequently assess the results. The organization and equipment can differ significantly, even within the same hospital. What works well in one department might not work in another. We must study the internal organization, care circuits, strengths and weakness, medical protocols employed by the department, support received by the medical specialties and its characteristics. Furthermore, we should know the main healthcare data: number of admissions and discharges, mean stay, readmissions, mortality, type of patients (emergency/scheduled), surgical activity and typical comorbidity, among others.Data and results analysisShared care, as with any other hospital activity, involves the periodic analysis of the work performed. This analysis requires, at the very least, the hospital's most up-to-date minimum basic data set (MBDS). It is also important to establish and maintain registries of all the diseases, conditions and other issues necessary for a good management and assessment of initiatives undertaken. These registries will helps us understand the results and identify what we are doing well and what we are doing poorly, as well as compare our center with other centers or with the literature. This data analysis is essential, given that the results from shared care reflect those of other departments, and it is not easy to demonstrate its efficiency.Discharge reportThe hospital discharge report is a summary of the medical care provided to a patient. The report must contain the necessary information to understand the reasons for and the evolution of the hospitalization and facilitate subsequent follow-up. There can only be one discharge report per hospitalization, and the report is legally regulated. Its preparation and delivery is the full responsibility of the physician of the department in charge of treating the patient.<a class="elsevierStyleCrossRefs" href="#bib0540">51–53</a>Even if more than one physician treats the patient, as happens with interconsultations and shared care, there can only be a single discharge report, not only because of the legal imperative, but also to avoid duplications, contradictions and confusion for the patient and physicians in the follow-up. We should integrate the information we deem necessary in the outcome section (or in a separate section) and always identify ourselves clearly. If for any reason we deem it necessary to create an independent report, it should always been prepared with the understanding and approval of the physician from the department responsible for the patient. The report should be consistent with and not contradict the main report and should specify that it is an appendix. Lastly, we should clearly explain to the patient and their family what written information we give and why we give it.Medical areaSomething similar to that described in the surgery department could be happening in the hospital's medical area. We have effective oral and parenteral drugs that can prevent or shorten hospitalizations. We also have safer and more effective medical treatments (endoscopies, catheterizations, drainages) that allow for outpatient use or short hospitalizations, as well as short-stay units, outpatient centers and home care, among other healthcare modalities.<a class="elsevierStyleCrossRef" href="#bib0555">54</a> These advances might be selecting patients who remain hospitalized in medical departments, increasing the mean age and complexity of management and hindering the activity of physician specialists. As with surgeons, training is increasingly more specialized, and the techniques are gaining ground on the symptoms. There is increasing political-healthcare pressure on the waiting lists for the techniques of the various specialties. This situation could be reflected in the detected increase in the number of interconsultations requested by the medical area.<a class="elsevierStyleCrossRef" href="#bib0560">55</a> There are good results from shared care in psychiatry,<a class="elsevierStyleCrossRefs" href="#bib0440">31,56</a> and the experiences of internists assigned to medical services are starting to be published.<a class="elsevierStyleCrossRef" href="#bib0570">57</a>ConclusionsShared care represents a significant change in the current hospital care model. This model was brought about by pressure from the surgery departments (and increasingly by physicians), especially on the internal medicine department. The pressure is due to the increase in the medical comorbidity and complexity of the patients, as well as more specialized medical training and changes in political-healthcare priorities, which involve a greater demand for broad and deep collaboration. It requires changes in the mentality and routine of the involved physicians. Shared care is proving to be highly effective and profitable.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:20 [ 0 => array:3 [ "identificador" => "xres599580" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec613969" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres599579" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec613968" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Characteristics of hospitalized surgical patients" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Challenges and problems of surgery departments" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Increased need for collaboration" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Interconsultation" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Shared care" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Patients eligible for shared care" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Who should provide the shared care?" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Internist characteristics" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Concerns to overcome" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "Work setting study" ] 14 => array:2 [ "identificador" => "sec0055" "titulo" => "Data and results analysis" ] 15 => array:2 [ "identificador" => "sec0060" "titulo" => "Discharge report" ] 16 => array:2 [ "identificador" => "sec0065" "titulo" => "Medical area" ] 17 => array:2 [ "identificador" => "sec0070" "titulo" => "Conclusions" ] 18 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of interest" ] 19 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-05-14" "fechaAceptado" => "2015-05-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec613969" "palabras" => array:5 [ 0 => "Remission and consultation" 1 => "Hospitalised patients" 2 => "Internal medicine" 3 => "Perioperative care" 4 => "Shared care" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec613968" "palabras" => array:5 [ 0 => "Remisión y consulta" 1 => "Pacientes ingresados" 2 => "Medicina Interna" 3 => "Atención perioperatoria" 4 => "Asistencia compartida" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Surgical departments have increasing difficulties in caring for their hospitalised patients due to the patients’ advanced age and comorbidity, the growing specialization in medical training and the strong political-healthcare pressure that a healthcare organization places on them, where surgical acts take precedence over other activities. The pressure exerted by these departments on the medical area and the deficient response by the interconsultation system have led to the development of a different healthcare organization model: Shared care, which includes perioperative medicine. In this model, 2 different specialists share the responsibility and authority in caring for hospitalised surgical patients.Internal medicine is the most appropriate specialty for shared care. Internists who exercise this responsibility should have certain characteristics and must overcome a number of concerns from the surgeon and anesthesiologist." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Los servicios quirúrgicos tienen dificultades crecientes en la atención a sus pacientes ingresados debido a la mayor edad y comorbilidad, a una formación médica en creciente especialización y a la fuerte presión político-sanitaria que impone una organización asistencial donde prima el acto quirúrgico frente a las demás actividades. La presión que ejercen estos servicios sobre el área médica y la respuesta deficiente ofrecida por el sistema de interconsulta han provocado el desarrollo de un modelo diferente de organización asistencial: la asistencia compartida, la cual incluye la medicina perioperatoria. En ella 2 especialistas diferentes comparten la responsabilidad y autoridad en la atención de un paciente quirúrgico ingresado.Medicina Interna es la especialidad más adecuada para la asistencia compartida. El internista que la ejerza ha de tener unas características determinadas y debe superar una serie de temores del cirujano y del anestesista." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Montero Ruiz E, por el Grupo de Trabajo de Asistencia Compartida e Interconsultas de la Sociedad Española de Medicina Interna (SEMI). Asistencia compartida (comanagement). Rev Clin Esp. 2016;216:27–33." ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Interconsultations \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Shared care \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• On demand \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• For all patients in the department \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Limited to reason for consultation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Comprehensive-overall care \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Poor communication among physicians \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Fluid communication among physicians \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Coordination problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Good coordination \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Recommendations should be offered \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Decisions are made and carried out \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Very limited responsibility \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Shared responsibility \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab980918.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Differences between Interconsultations and Shared Care." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:57 [ 0 => array:3 [ "identificador" => "bib0290" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Five system barriers to achieving ultrasafe health care" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. 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Shared care (comanagement)

Asistencia compartida (comanagement)

E. Montero Ruiz, por el Grupo de Trabajo de Asistencia Compartida e Interconsultas de la Sociedad Española de Medicina Interna (SEMI)

Servicio de Medicina Interna, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In terms of the support that medical services provide surgery departments&#44; we should be very aware that these services have very specific local and individual characteristics&#46; Each hospital has their own unique structure&#44; equipment and operation&#44; even when compared to theoretically similar centers&#46; Within the same hospital&#44; the various medical and surgery departments are very different one from another in terms of the approach and organization for this type of healthcare activity&#46; The same can be said of the physicians involved in this activity&#44; even in the same department&#44; with completely different behaviors and work styles in many cases&#46; The support should therefore be analyzed and executed from an individual perspective&#44; and the general information and available literature should be assessed and adapted to each specific context&#46; We should keep in mind that to perform the safest work for our patients and for ourselves we might need to let go of traditions and autonomy that some practitioners believe&#44; erroneously&#44; are necessary to conduct their work effectively and pleasantly&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present this document as a position statement of the Shared Care and Interconsultations Workgroup of the Spanish Society of Internal Medicine on the relevant concepts and issues of a special form of medical support for surgery departments&#44; which entails a profound change in the organization of the hospital medical care&#58; shared care &#40;comanagement&#41;&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Characteristics of hospitalized surgical patients</span><p id="par0015" class="elsevierStylePara elsevierViewall">The evolution of surgical and anesthetic techniques and procedures has enabled operations for increasingly older patients with greater comorbidity&#46; Moreover&#44; the development of outpatient surgery with short stays has resulted in many surgical patients not requiring hospital admission&#44; or only needing admission for a brief period&#46; One of the consequences of these developments is that patients hospitalized in surgery departments are increasingly older and&#44; in particular&#44; have increasingly more comorbidity&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">2&#44;3</span></a> It is estimated that at least 60&#37; of surgical patients have significant medical comorbidities&#44; with an even greater prevalence in the elderly&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Comorbidity due to acute or chronic diseases increases hospital mortality&#44; stays&#44; costs and readmissions&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">5</span></a> For the last 60 years&#44; it has been known that comorbidity is especially significant in the surgical area because comorbidity is the origin of more than 80&#37; of postoperative deaths&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">6</span></a> In elderly patients&#44; comorbidity is even more influential than age in terms of the outcome of surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">7</span></a> Postsurgical complications are much more important than the preoperative risk in postoperative survival&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">8</span></a> but even more important is the delay in diagnosing and treating these complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">9&#44;10</span></a> A 100&#37; increase is expected in the onset of complications in surgical patients in the next 2 decades&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">An issue to consider with patients hospitalized in surgery departments is that there is a significant percentage of these patients who&#44; for various reasons&#44; do not undergo operations&#46; This percentage is different in each specialty surgical&#46; This percentage reaches 23&#37; in a number of series<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">12</span></a> and 46&#37; for patients in general surgery for whom an interconsultation with internal medicine is requested&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">13</span></a> These percentages are significant because the surgeons have special difficulties in providing care for this patient group&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">12&#44;14</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Challenges and problems of surgery departments</span><p id="par0030" class="elsevierStylePara elsevierViewall">At present&#44; surgery departments face a number of challenges and problems that hinder their activity and increase the need for medical support&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Age and comorbidity of their patients</span>&#46; Aspects already mentioned above&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Medical training&#46;</span> Training provided to residents in general and to those of the surgical area in particular is increasingly specialized&#44; with less general medical knowledge&#46; When working as surgeons&#44; residents &#40;in most cases&#41; are dedicated to specific areas of their specialty&#44; further narrowing the field of their competencies and skills&#44; which increases the difficulties when providing care for their hospitalized patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Healthcare organization&#46;</span> In general&#44; surgery departments have a healthcare organization that greatly impedes the daily follow-up of their patients&#44; by frequently switching the surgeon who visits the patient&#44; in many cases switching on a daily basis&#46; This problem with following-up a patient&#39;s clinical evolution is especially relevant in the case of medical diseases&#46; Furthermore&#44; this organization dilutes responsibility for the patient&#44; promotes errors and greatly impedes communication&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">15</span></a> The daily change in the surgeons who make the rounds increases the hospital stay and slows decision making&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Political-healthcare pressure</span>&#46; The pressure caused by waiting lists is unbalancing the surgery departments&#46; The weight of the surgical act with respect to other departmental activities is disproportionate&#46; Surgeons are increasingly being directed to only consider whether to operate and when&#44; leaving the other considerations in second place&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Increased need for collaboration</span><p id="par0055" class="elsevierStylePara elsevierViewall">As a result of the facts and circumstances mentioned above&#44; there is an increasing need for general practitioners during surgery hospitalizations&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">17</span></a> Additionally&#44; the more specialized the physician&#44; the more interconsultations are requested&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">18</span></a> This increased need for collaboration is manifested by the increased number of interconsultations requested of the medical area by surgery departments&#44; which creates a high risk of subjecting the patient to a &#8220;circus of consultants&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">19</span></a> This increase in the number of requests for interconsultations is especially intense for internal medicine&#46; In fact&#44; between 2000 and 2007&#44; the number of interconsultations requested of this department by surgery units increased 60&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Interconsultation</span><p id="par0060" class="elsevierStylePara elsevierViewall">The interconsultation represents the standard system of healthcare collaboration among the various hospital departments&#58; requesting another physician to provide their opinion concerning the diagnosis&#44; the regimen to follow and the treatment or to assume direct responsibility for one of the patient&#39;s specific problems&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">20</span></a> Although the actual volume remains unknown&#44; an approximate calculation estimated that the Spanish departments of internal medicine received more than 111&#44;000 interconsultation requests from the surgery area in 2006&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">21</span></a> However&#44; medical interconsultations suffer from numerous problems in the implementation mechanism&#44;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">21</span></a> the delimiting or transferring of responsibility for the patient&#44;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">21</span></a> the transmission of information&#44;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">22&#44;23</span></a> the call&#47;rejection effect on the consultants<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">2</span></a> and applicants&#44;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">24</span></a> the seasonal nature of requests&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">2</span></a> the urgency of interconsultations&#44;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">25&#44;26</span></a> the unjustified repetitions<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">25&#8211;27</span></a> and the delays in their request&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">26&#44;28</span></a> For these and other reasons&#44; interconsultations have for years been known to be expensive<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">30</span></a> and rarely effective&#44;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">29</span></a> statements that have yet to be contradicted&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Shared care</span><p id="par0065" class="elsevierStylePara elsevierViewall">The pressure exerted by surgery departments on the medical area and the deficient response by the interconsultation system have led to the development in the last few years of a new healthcare organization model&#58; shared care&#46; This model is a method for organizing and improving the medical care of patients hospitalized in surgery departments&#44; in which 2 different specialists share a patient&#39;s medical care&#46; It is defined as shared responsibility and authority in the handling of a hospitalized patient&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">20</span></a> The physician specialist takes charge of the patient&#39;s medical problems &#40;pre-existing or newly diagnosed&#41;&#44; from the patient&#39;s admission to the surgery department to their hospital discharge&#44; without needing to be consulted&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">20</span></a> Although shared care and interconsultations are medical support systems for surgery departments&#44; these methods have significant differences &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; This form of healthcare organization reduces the surgical specialist&#39;s concern about not diagnosing serious medical problems&#44; provides them time to focus on the specific aspects of their sphere of action and reduces legal risks&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">31</span></a> Shared care is showing its efficacy in Spain<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">14</span></a> and beyond&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">32</span></a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Perioperative medicine is shared care focused exclusively on the perioperative period&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">33</span></a> Although there is no one universally accepted definition&#44; even for establishing the so-called perioperative period&#44; perioperative medicine is understood to cover all medical activity related to the surgical process&#46; Its purpose is to achieve the best conditions for the patient at the time of the surgery&#44; that the surgery is performed as safely and effectively as possible and that the fewest possible postoperative complications arise&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">33</span></a></p></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Patients eligible for shared care</span><p id="par0075" class="elsevierStylePara elsevierViewall">A frequent question is whether shared care should extend to all hospitalized patients in a surgery department&#44; regardless of their condition and medical history or to just certain groups&#46; For the latter case&#44; a simple and automatic selection system should be used&#46; However&#44; there are no sufficiently safe and easy systems for implementation&#46; Some of the criteria employed include&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Age&#46;</span> An important criterion that is easy to apply but does not differentiate the risk or the postsurgery prognosis well&#46; For this&#44; comorbidity&#44; medical history and type of surgery are more important than age&#46;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">34&#44;35</span></a> Many high-risk patients who should receive shared care would be below our established cutoff age&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Type of hospitalization &#40;emergency&#47;scheduled&#41;&#46;</span> Simple application criterion&#46; In principle&#44; it is easy to understand that emergency patients would benefit the most&#44; given that they are at greater risk&#44; and that unscheduled patients have lower risk&#44; are clinically stable and have already been assessed in the preanesthesia visit&#46; However&#44; this is not a good criterion&#46; For example&#44; which patient would benefit more from shared care&#58; a 25-year-old man with no medical history who is admitted for acute appendicitis or a 60-year-old patient with a history of diabetes mellitus&#44; arterial hypertension&#44; obesity&#44; and myocardial infarction a year ago and who is admitted for scheduled surgery for colon cancer&#63;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Type of patient &#40;operated&#47;not operated&#41;&#46;</span> In the surgery departments&#44; between 8&#37; and 23&#37; of hospitalized patients do not&#44; for various reasons&#44; undergo operations&#58; their disease does not require surgery at that time&#44; their disease requires surgery but the patient is in no condition to be operated on or the patient is admitted for diagnostic tests&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">12</span></a> If we only treat patients with surgery &#40;perioperative medicine&#41;&#44; those patients who do not undergo surgery will not receive shared care&#46; However&#44; surgeons have more problems in managing and following up patients who do not undergo surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">12</span></a> These patients would therefore be eligible for shared care&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Disease&#46;</span> In this case&#44; patients are selected by their medical condition &#40;e&#46;g&#46;&#44; hip fractures&#41;&#46; Although the results for these patients would be excellent&#44; a large number of the patients who could benefit from shared care would be excluded due to the highly selective process&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">36</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">At the request of the surgical specialist&#46;</span> This is the classical care model to apply in cases where there is no automatic selection system&#46; Operating on an on-demand system has many of the problems presented by classical interconsultations that we mentioned earlier&#46;</p></li></ul></p><p id="par0105" class="elsevierStylePara elsevierViewall">In addition to the lack of an effective and easy patient selection mechanism&#44; there is evidence that at least 90&#37; of patients hospitalized in surgery departments would benefit from shared care&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">37</span></a> Therefore&#44; all patients admitted to surgery departments should be considered eligible for shared care&#46; Assessing all patients at admission does not mean that the intensity applied to the follow-up will be the same&#46; This will depend on each patient&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Who should provide the shared care&#63;</span><p id="par0110" class="elsevierStylePara elsevierViewall">There have been experiments in shared care conducted by physicians of various medical specialties&#46; If we select a certain patient group and they receive treatment from the corresponding specialist&#44; good results are expected&#46; The broadest collaboration of this type is shared care with internists<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">38</span></a> and geriatricians<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">39</span></a> for hip fractures&#44; although there are lesser known examples such as assigning nephrologists to intensive care units&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">40</span></a> However&#44; these and other experiments are directed to a disease or group of diseases and are not patient focused&#46; Therefore&#44; given the type of patients admitted to hospitals&#44; the most likely scenario is the need to involve several specialists in the patient&#39;s care&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The simultaneous or consecutive actions of various specialties for a patient can cause numerous problems&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">41</span></a> The care can be redundant&#44; inefficient&#44; problematic and unsafe for the patients due to poor coordination and integration&#44;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">42</span></a> causing problems of polypharmacy&#44; test duplication&#44; confusing and even conflicting medical comments or indications&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">43</span></a> The number of specialties that provide care for the patient is associated with an increased risk of adverse events and inadequate care&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">41</span></a> Even &#8220;excessive&#8221; specialization can be harmful&#44; given that medical errors can result from the specialization itself&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">44</span></a> Possibly due to these reasons&#44; the internist has for decades been the specialist physician most required by surgery departments&#44; due to the internist&#39;s versatility and ability&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">45</span></a> More than 90&#37; of perioperative interconsultations are resolved by internists&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">46</span></a> General practitioners also have better results than specialists in resolving the interconsultations&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">47</span></a> Internal medicine is therefore the most appropriate specialty for shared care&#46; Due to their overall patient-focused &#40;not disease-focused&#41; view&#44; internal medicine has the most experience in this type of collaboration among departments&#46; Internal medicine departments also consider this need in their teaching programs<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">48</span></a> and in the strategic objectives of the Spanish Society of Internal Medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">49</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Although internists who work in a surgery department can be completely independent of the department of internal medicine&#44; it is advisable that they maintain an organic dependence on the latter&#46; It is very important to have a good relationship with the department because their collaboration is needed in the support they can provide other staff members and&#44; of course&#44; in the transfers from the surgery departments to internal medicine&#46; This is applicable to related activities&#44; such as interconsultations&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Internist characteristics</span><p id="par0125" class="elsevierStylePara elsevierViewall">The first thing an internist who works in a surgery department should know is what the surgeons and anesthesiologists want and do not want from the internist&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">What do surgeons and anesthesiologists want&#63;</span> The ability to operate on the patient as soon as possible and under the best possible conditions and that the postoperative period proceeds rapidly and without complications&#46; For patients who do not undergo an operation for whatever reason&#44; the surgeons&#8217; main interest centers on discharging the patients&#46; What they expect from the internist is empathy and assistance in achieving these objectives&#44; which focus only on the relevant issues for surgery&#44; leaving other issues that could be assessed&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">50</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">What do surgeons and anesthesiologists not want&#63;</span> They do not want to be told how and when to do their job&#59; a lack of respect for their method of thinking and working&#59; little motivation on the part of the internist&#59; a lack of focus on the issues that are important to them&#59; and an internist who is an obstacle or a drag on their daily activity&#46;</p></li></ul></p><p id="par0140" class="elsevierStylePara elsevierViewall">The internist should encompass a number of specific qualities and characteristics in order to properly conduct this activity&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Work style</span>&#46; Hospital medical specialists are likely to be more individualistic&#46; They are accustomed to making decisions alone&#44; only consulting when they feel it is necessary&#46; They also delve into all of the healthcare aspects that could be involved in the patient&#44; without focusing exclusively &#8220;on their parcel&#8221; or the reason for the consultation or hospitalization&#46; The internist who works in surgery departments must change these characteristics and priorities&#46; The internist must work in a team with other workmates and must subordinate themselves to their workmate on some issues&#44; given that the latter is the one who must make the most important decisions&#46; Furthermore&#44; the internist should focus only on that which interests the surgeon&#44; relegating the other activities and diagnoses for later or for an external consultation&#46; In this work team&#44; we should not forget the anesthesiologist&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Personal qualities&#46;</span> The internist assigned to a surgery department will be trained&#44; capable of working in a team and adaptable&#44; given that each department is different&#46; Furthermore&#44; internists should have an open mind and be decisive and pragmatic&#46; Excessively thorough and meticulous individuals will not adapt well to this work environment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Extensive responsibility for the patient&#46;</span> The internist will work in the same manner as in the internal medicine rooms&#44; making decisions&#44; requesting tests and prescribing treatments&#44; with the only condition of coordinating with the surgeon and ensuring the least possible hindrance to the surgeon&#39;s dynamic&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Without restriction</span> &#8220;<span class="elsevierStyleItalic">by specialty</span>&#8221;&#46; The internist should act as such in the broadest sense&#44; where none of the patient&#39;s problems are foreign to the internist&#46; The internist has the ability to intervene in almost all situations that can occur with the patient&#46; If the internist believes that the analgesia is insufficient&#44; they should correct the anesthesiologist&#46; Similarly&#44; if there appears to be a surgical wound infection&#44; the internist should tell the surgeon&#46; The internist cannot say &#8220;it is responsibility of others&#8221; and look away&#46; The internist&#39;s purpose is the patient and then the surgeon&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Concerns to overcome</span><p id="par0165" class="elsevierStylePara elsevierViewall">The start of shared care with internists in a surgery department entails a number of doubts and concerns by the surgeon and anesthesiologists&#44; which must be given significant consideration&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">They do not replace the surgeons and anesthesiologists&#46;</span> Having internists in the surgery ward does not mean that the surgeons and anesthesiologists are replaced&#46; Each will continue with their tasks&#44; without having to worry about processes for which they are not well qualified&#46; For the same reason&#44; obligations for which the internists are not sufficiently qualified cannot be shifted to them&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Key decisions&#46;</span> In a surgery department&#44; the main decisions are whether the patient should be admitted&#44; whether they have a surgical indication&#44; whether they are in a condition to undergo an operation or whether they should be discharged&#46; These decisions are to be made by the surgeons and anesthesiologists&#46; The internist&#44; in every case&#44; can help with some of these decisions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Consensus&#46;</span> There is the ingrained idea that the internist&#44; due to their knowledge and individualism&#44; makes decisions without taking into account the surgeons and anesthesiologists&#46; All activity conducted by the internist&#44; especially that which interferes with the surgeons and anesthesiologists&#44; should be agreed upon beforehand&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Extending the hospitalization&#46;</span> There is a deep-seated fear that the internist will request tests or start treatments that extend the hospitalization beyond what is strictly necessary for the surgical process&#46; This should not be the case&#46; Tests and treatments will be indicated without interfering with this process&#46; If the surgical problem has been resolved&#44; the patient should leave the surgery department&#46; If in the condition to do so&#44; the patient will be discharged&#44; although they will be referred to internal medicine for consultation&#46; If not&#44; the patient will be transferred to the department of internal medicine&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Work setting study</span><p id="par0190" class="elsevierStylePara elsevierViewall">The implementation of shared care in a specific hospital department requires a deep understanding of its conditions and situation in order to plan for its needs and subsequently assess the results&#46; The organization and equipment can differ significantly&#44; even within the same hospital&#46; What works well in one department might not work in another&#46; We must study the internal organization&#44; care circuits&#44; strengths and weakness&#44; medical protocols employed by the department&#44; support received by the medical specialties and its characteristics&#46; Furthermore&#44; we should know the main healthcare data&#58; number of admissions and discharges&#44; mean stay&#44; readmissions&#44; mortality&#44; type of patients &#40;emergency&#47;scheduled&#41;&#44; surgical activity and typical comorbidity&#44; among others&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Data and results analysis</span><p id="par0195" class="elsevierStylePara elsevierViewall">Shared care&#44; as with any other hospital activity&#44; involves the periodic analysis of the work performed&#46; This analysis requires&#44; at the very least&#44; the hospital&#39;s most up-to-date minimum basic data set &#40;MBDS&#41;&#46; It is also important to establish and maintain registries of all the diseases&#44; conditions and other issues necessary for a good management and assessment of initiatives undertaken&#46; These registries will helps us understand the results and identify what we are doing well and what we are doing poorly&#44; as well as compare our center with other centers or with the literature&#46; This data analysis is essential&#44; given that the results from shared care reflect those of other departments&#44; and it is not easy to demonstrate its efficiency&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discharge report</span><p id="par0200" class="elsevierStylePara elsevierViewall">The hospital discharge report is a summary of the medical care provided to a patient&#46; The report must contain the necessary information to understand the reasons for and the evolution of the hospitalization and facilitate subsequent follow-up&#46; There can only be one discharge report per hospitalization&#44; and the report is legally regulated&#46; Its preparation and delivery is the full responsibility of the physician of the department in charge of treating the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">51&#8211;53</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Even if more than one physician treats the patient&#44; as happens with interconsultations and shared care&#44; there can only be a single discharge report&#44; not only because of the legal imperative&#44; but also to avoid duplications&#44; contradictions and confusion for the patient and physicians in the follow-up&#46; We should integrate the information we deem necessary in the outcome section &#40;or in a separate section&#41; and always identify ourselves clearly&#46; If for any reason we deem it necessary to create an independent report&#44; it should always been prepared with the understanding and approval of the physician from the department responsible for the patient&#46; The report should be consistent with and not contradict the main report and should specify that it is an appendix&#46; Lastly&#44; we should clearly explain to the patient and their family what written information we give and why we give it&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Medical area</span><p id="par0210" class="elsevierStylePara elsevierViewall">Something similar to that described in the surgery department could be happening in the hospital&#39;s medical area&#46; We have effective oral and parenteral drugs that can prevent or shorten hospitalizations&#46; We also have safer and more effective medical treatments &#40;endoscopies&#44; catheterizations&#44; drainages&#41; that allow for outpatient use or short hospitalizations&#44; as well as short-stay units&#44; outpatient centers and home care&#44; among other healthcare modalities&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">54</span></a> These advances might be selecting patients who remain hospitalized in medical departments&#44; increasing the mean age and complexity of management and hindering the activity of physician specialists&#46; As with surgeons&#44; training is increasingly more specialized&#44; and the techniques are gaining ground on the symptoms&#46; There is increasing political-healthcare pressure on the waiting lists for the techniques of the various specialties&#46; This situation could be reflected in the detected increase in the number of interconsultations requested by the medical area&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">55</span></a> There are good results from shared care in psychiatry&#44;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">31&#44;56</span></a> and the experiences of internists assigned to medical services are starting to be published&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">57</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0215" class="elsevierStylePara elsevierViewall">Shared care represents a significant change in the current hospital care model&#46; This model was brought about by pressure from the surgery departments &#40;and increasingly by physicians&#41;&#44; especially on the internal medicine department&#46; The pressure is due to the increase in the medical comorbidity and complexity of the patients&#44; as well as more specialized medical training and changes in political-healthcare priorities&#44; which involve a greater demand for broad and deep collaboration&#46; It requires changes in the mentality and routine of the involved physicians&#46; Shared care is proving to be highly effective and profitable&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Surgical departments have increasing difficulties in caring for their hospitalised patients due to the patients&#8217; advanced age and comorbidity&#44; the growing specialization in medical training and the strong political-healthcare pressure that a healthcare organization places on them&#44; where surgical acts take precedence over other activities&#46; The pressure exerted by these departments on the medical area and the deficient response by the interconsultation system have led to the development of a different healthcare organization model&#58; Shared care&#44; which includes perioperative medicine&#46; In this model&#44; 2 different specialists share the responsibility and authority in caring for hospitalised surgical patients&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Internal medicine is the most appropriate specialty for shared care&#46; Internists who exercise this responsibility should have certain characteristics and must overcome a number of concerns from the surgeon and anesthesiologist&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Los servicios quir&#250;rgicos tienen dificultades crecientes en la atenci&#243;n a sus pacientes ingresados debido a la mayor edad y comorbilidad&#44; a una formaci&#243;n m&#233;dica en creciente especializaci&#243;n y a la fuerte presi&#243;n pol&#237;tico-sanitaria que impone una organizaci&#243;n asistencial donde prima el acto quir&#250;rgico frente a las dem&#225;s actividades&#46; La presi&#243;n que ejercen estos servicios sobre el &#225;rea m&#233;dica y la respuesta deficiente ofrecida por el sistema de interconsulta han provocado el desarrollo de un modelo diferente de organizaci&#243;n asistencial&#58; la asistencia compartida&#44; la cual incluye la medicina perioperatoria&#46; En ella 2 especialistas diferentes comparten la responsabilidad y autoridad en la atenci&#243;n de un paciente quir&#250;rgico ingresado&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Medicina Interna es la especialidad m&#225;s adecuada para la asistencia compartida&#46; El internista que la ejerza ha de tener unas caracter&#237;sticas determinadas y debe superar una serie de temores del cirujano y del anestesista&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Montero Ruiz E&#44; por el Grupo de Trabajo de Asistencia Compartida e Interconsultas de la Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;&#46; Asistencia compartida <span class="elsevierStyleItalic">&#40;comanagement&#41;</span>&#46; Rev Clin Esp&#46; 2016&#59;216&#58;27&#8211;33&#46;</p>"
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; On demand&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; For all patients in the department&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2015.09.002

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