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The Internal Medicine of the 21st century: Organizational and operational standards
La Medicina Interna del siglo xxi: estándares de organización y funcionamiento
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Casariego-Vales, A. Zapatero-Gaviria, F.J. Elola-Somoza" "autores" => array:4 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Casariego-Vales" "email" => array:1 [ 0 => "emilio.casariego.vales@sergas.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Zapatero-Gaviria" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "F.J." "apellidos" => "Elola-Somoza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:2 [ "colaborador" => "on behalf of the Committee of Standards for Internal Medicine Units" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">◊</span>" "identificador" => "fn0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Fundación Instituto para la Mejora de la Asistencia Sanitaria (IMAS), Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La Medicina Interna del siglo <span class="elsevierStyleSmallCaps">xxi</span>: estándares de organización y funcionamiento" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2025 "Ancho" => 3324 "Tamanyo" => 438801 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Healthcare process for complex chronic patients</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviation</span>: PC, primary care.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 2014, internal medicine units (IMU) managed 19.8% of the discharged patients older than 14 years, admitted to hospitals of the Spanish National Health System (NHS).<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> If we consider other forms of healthcare, such as interconsultations, it is possible to estimate that more than 25% of patients admitted to Spanish NHS hospitals are treated by IMUs. These data should be interpreted in the context of radical and accelerated transformations that are occurring in our society and that require a redefinition of healthcare models.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The 2013 RECALMIN study<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a> showed the organizational and healthcare aspects of IMUs, as well as areas that needed improvement and the need to adapt to the new conditions.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a> A number of internal medicine societies in developed countries have proposed new organizational models to adapt to the changes.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">6–9</span></a> However, these proposals are only partially exportable to the Spanish system. Therefore, The Spanish Society of Internal Medicine (SEMI) has developed the standards and recommendations that they consider essential in the organization and operation of IMUs in the Spanish NHS. This article covers the most relevant aspects of this task. We use the term “units” rather than the more common “departments” because the former is more comprehensive and includes units and areas of clinical management or other organizational forms of IM.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Objectives</span><p id="par0015" class="elsevierStylePara elsevierViewall">The objectives of the IMU standards document are as follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0020" class="elsevierStylePara elsevierViewall">To define the role that an internal medicine department should play in the Spanish NHS.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0025" class="elsevierStylePara elsevierViewall">To identify the key healthcare processes.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0030" class="elsevierStylePara elsevierViewall">To define the standards of organization and operation for IMUs.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0035" class="elsevierStylePara elsevierViewall">To propose workloads resulting from the identified activities.</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology for preparing the consensus document</span><p id="par0040" class="elsevierStylePara elsevierViewall">We prepared a framework document entitled “The Internal Medicine Departments in the Spanish National Health System of the 21th century”, which identifies the potential gaps in operation and quality regarding the immediate future needs and in what measure the standards could contribute to filling those gaps.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> Subsequently, we created a Standards Committee, designated by the Board of Directors of SEMI, consisting of 12 physician internists with broad experience and vision in IM. We established 4 levels of participation: Board of Directors, Standards Committee, consultation with partners (via the Web) and presentation and discussion with the Heads of the IM Departments and Units.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Once an agreement was reached within the Committee and the proposal was approved by the Board of Directors of SEMI, the proposal was posted on the SEMI website, and contributions from members were requested. Lastly, the proposal was presented on September 24, 2016, during the Meeting of IM Department and Unit Managers.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Healthcare processes</span><p id="par0050" class="elsevierStylePara elsevierViewall">The proposed standards were organized by identifying the key, strategic and support processes of IMUs. The most common way of defining a department's process map is to relate it to the healthcare modalities; i.e., with the “structure where it is performed” (hospitalization, outpatient consultation, etc.).<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">8–12</span></a> In this document, SEMI has, as much as possible, linked the standards to healthcare processes covered by IMUs. The advantages of this approach are found in the complex chronic patient care process, which requires a wide assortment of healthcare modalities.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Key processes map</span><p id="par0055" class="elsevierStylePara elsevierViewall">We identified the following processes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>):</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">1. <span class="elsevierStyleItalic">Key healthcare processes</span></p><p id="par0065" class="elsevierStylePara elsevierViewall">1.A. Hospitalized patient care. The responsibility of the medical internist in providing care is divided into...<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">Directly responsible physician</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">Not directly responsible physician (interconsultation)</p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">1.B. Consultation with primary care or other specialties, either in a diagnostic consultation modality or a follow-up modality.</p><p id="par0085" class="elsevierStylePara elsevierViewall">1.C. Complex chronic patient care (patients with advanced age, functional limitation, mortality and resource consumption).<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">13–15</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">2. <span class="elsevierStyleItalic">Support processes:</span> Organizational structure and procedures of the IMUs.</p><p id="par0095" class="elsevierStylePara elsevierViewall">3. <span class="elsevierStyleItalic">Strategic processes</span></p><p id="par0100" class="elsevierStylePara elsevierViewall">3.A. Training</p><p id="par0105" class="elsevierStylePara elsevierViewall">3.B. Research</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Proposed standards</span><p id="par0110" class="elsevierStylePara elsevierViewall">The developed standards are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, and the full document can be accessed through the SEMI website.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">3</span></a> We have followed the Donabedian classification, differentiating standards for structure and for process.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">16,17</span></a> Result standards cannot be established yet. We propose the use of a common scorecard that enables the future establishment of these standards.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Standards for the healthcare process for hospitalized patients</span><p id="par0115" class="elsevierStylePara elsevierViewall">This process has been defined by a sequence of activities: admission, follow-up and discharge (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">18,19</span></a> We differentiated the care of patients admitted to an IMU and the interconsultation for patients hospitalized in other units, presenting them separately because there are differentiated organizational and procedural considerations.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Standards for the process of support for consulting with primary care and other specialties</span><p id="par0120" class="elsevierStylePara elsevierViewall">In both cases, we emphasize the importance of maintaining a structured relationship. The classical consultation process is face-to-face and is subdivided into reception, care/supplementary examinations or interconsultation and discharge/follow-up. The document of standards identifies consultations (face-to-face or not) either in a single act (“high resolution”) or several (first and successive). The connection between the various types of consultation depends on the reason behind it (establishing a diagnosis or performing follow-up of a diagnosed process).<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Standards for the complex chronic patient care and continuity of care</span><p id="par0125" class="elsevierStylePara elsevierViewall">International experience has shown that systematic care for complex chronic patients reduces the frequency of admission, the length of stay, the rate of emergency consultations and the consumption of drug products.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">20–22</span></a> The SEMI standards (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) are based on the Strategy for Approaching Chronicity<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">23</span></a> and other documents.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">13–15</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Standards for the organizational structure and procedures of internal medicine units</span><p id="par0130" class="elsevierStylePara elsevierViewall">All IMUs must have an organizational structure appropriate for its size and functions. The key issues are staffing the unit with a director (with dedication based on the complexity of the healthcare team) and having an Organizational Manual and a system of indicators (which include quality and safety), focused on results. Furthermore, an annual report should be created, a record of complications should be available, as well as a scorecard that enables the follow-up of the activity. IMUs should avoid low-value interventions, such as those indicated by SEMI.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">IMUs must comply with the legal obligations regarding information systems. We advise following the recommendations for the preparation of hospital discharge reports in medical specialties.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Training standards</span><p id="par0140" class="elsevierStylePara elsevierViewall">In terms of continuing education, IMUs should have a plan that is suitable for its portfolio of services. Each practitioner must complete at least 40 classroom hours or 4 European Credit Transfer and Accumulation System (ECTS) credits a year. For hospitals where the work shift is spread throughout the medical area, the center is advised to ensure that the practitioners of the various specialties that cover the shift have the necessary competencies through specific training programs.</p><p id="par0145" class="elsevierStylePara elsevierViewall">With regard to graduate training, the accredited IMUs must have a teacher for every 5 residents in training. The teachers must have an assigned time to conduct their work and have a training program that includes the general and specific competencies for each area. The requirements established for undergraduate training are similar.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Research standards</span><p id="par0150" class="elsevierStylePara elsevierViewall">All IMUs are advised to conduct research projects, especially applied research, and to participate in at least one SEMI registry. All IMUs are also advised to participate in competitive bids for research projects and to promote the creation of doctoral theses. All IMUs must have at least one of its members as signatory of a published article in an indexed scientific journal every year.</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Estimating the workloads</span><p id="par0155" class="elsevierStylePara elsevierViewall">The workloads are indicative and are based on the RECALMIN study,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a> on the Ministry of Health documents,<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">11–13,17</span></a> the European Federation of Internal Medicine documents<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a> and the Royal College of Physicians documents,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> as well as on the opinion of the Committee members. The proposal is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. All medical internists must devote a part of their workday to management, training and research tasks. As a guideline, we propose devoting 20% of the workday to these activities, which would be increased to at least 60% for the heads of the IMUs and to 40% for teachers.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Review</span><p id="par0160" class="elsevierStylePara elsevierViewall">The SEMI document must be reviewed within a maximum term of 4 years.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0165" class="elsevierStylePara elsevierViewall">This study was funded entirely by SEMI.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres947404" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec919886" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres947403" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec919887" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Objectives" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methodology for preparing the consensus document" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Healthcare processes" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Key processes map" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Proposed standards" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Standards for the healthcare process for hospitalized patients" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Standards for the process of support for consulting with primary care and other specialties" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Standards for the complex chronic patient care and continuity of care" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Standards for the organizational structure and procedures of internal medicine units" ] 4 => array:2 [ "identificador" => "sec0050" "titulo" => "Training standards" ] 5 => array:2 [ "identificador" => "sec0055" "titulo" => "Research standards" ] ] ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Estimating the workloads" ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "Review" ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "Funding" ] 12 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflict of interests" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-01-26" "fechaAceptado" => "2017-06-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec919886" "palabras" => array:4 [ 0 => "Spanish Society of Internal Medicine" 1 => "Internal Medicine units" 2 => "Healthcare processes" 3 => "Standards" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec919887" "palabras" => array:4 [ 0 => "Sociedad Española de Medicina Interna" 1 => "Unidades de Medicina Interna" 2 => "Procesos asistenciales" 3 => "Estándares" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The Spanish Society of Internal Medicine has developed a consensus document on the standards and recommendations that they consider essential to the organization of internal medicine units for conducting their activities efficiently and with high quality. We defined 3 groups of key processes: the care of acutely ill adult patients, the comprehensive care of complex chronic patients and the examination of a patient with a difficult diagnosis and no organ-specific disease. As support processes, we identified the structure and operation of the Internal Medicine units. As strategic processes, we identified training and research. The main subprocesses are structured below, and we established the standards and recommendations for each of them. Lastly, we proposed resulting workloads. The prepared standards must be reviewed within a maximum of 4 years.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La Sociedad Española de Medicina Interna ha elaborado un documento de consenso sobre los estándares y recomendaciones que considera fundamentales en la organización de las unidades de Medicina Interna para desarrollar sus actividades con eficiencia y calidad. Se definieron 3 grupos de procesos clave: la atención al paciente adulto agudamente enfermo, el estudio del paciente con un diagnóstico difícil sin enfermedad específica de órgano y la asistencia integral del paciente crónico complejo. Como procesos de soporte se identificaron la estructura y el funcionamiento de las unidades de Medicina Interna, y como procesos estratégicos, la formación y la investigación. A continuación, se estructuraron los principales subprocesos y se establecieron los estándares y recomendaciones para cada uno de ellos. Por último, se proponen las cargas de trabajo derivadas. Los estándares elaborados deben ser revisados en el plazo máximo de 4 años.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Casariego-Vales E, Zapatero-Gaviria A, Elola-Somoza FJ, en nombre del Comité de Estándares de Unidades de Medicina Interna. La Medicina Interna del siglo <span class="elsevierStyleSmallCaps">xxi</span>: estándares de organización y funcionamiento. Rev Clin Esp. 2017;217:526–533.</p>" ] 1 => array:3 [ "etiqueta" => "◊" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The names of the members of the Committee of Standards for Internal Medicine Units are listed in the <a class="elsevierStyleCrossRef" href="#sec0080">Appendix</a>.</p>" "identificador" => "fn0005" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0175" class="elsevierStylePara elsevierViewall">José Carlos Arévalo Lorido: Department of Internal Medicine, Hospital of Zafra, Badajoz, Spain.</p> <p id="par0180" class="elsevierStylePara elsevierViewall">Raquel Barba Martín: Internal Medicine Unit, Hospital Infanta Cristina, Madrid, Spain.</p> <p id="par0185" class="elsevierStylePara elsevierViewall">Emilio Casariego Vales: Department of Internal Medicine, Hospital Lucus Augusti, Lugo, Spain.</p> <p id="par0190" class="elsevierStylePara elsevierViewall">M. Victoria Egurbide: Department of Internal Medicine, Hospital of Cruces, Baracaldo, Vizcaya, Spain.</p> <p id="par0195" class="elsevierStylePara elsevierViewall">Ricardo Gómez Huelgas: Department of Internal Medicine, Hospital Carlos Haya, Malaga, Spain.</p> <p id="par0200" class="elsevierStylePara elsevierViewall">Adriana González Munera: Department of Internal Medicine, University General Hospital Gregorio Marañón, Madrid, Spain.</p> <p id="par0205" class="elsevierStylePara elsevierViewall">Fernando de la Iglesia: Department of Internal Medicine, University Hospital Complex A Coruña, Spain.</p> <p id="par0210" class="elsevierStylePara elsevierViewall">Javier Moreno Martínez: Department of Internal Medicine, University Hospital Miguel Servet, Zaragoza, Spain.</p> <p id="par0215" class="elsevierStylePara elsevierViewall">Rosa María Ramos Guevara: Department of Internal Medicine, Hospital Morales Meseguer, Murcia, Spain.</p> <p id="par0220" class="elsevierStylePara elsevierViewall">Pilar Román Sánchez: Department of Internal Medicine, General Hospital of Requena, Valencia, Spain.</p> <p id="par0225" class="elsevierStylePara elsevierViewall">Roser Solans Laqué: Department of Internal Medicine, Hospital Vall d’Hebron, Barcelona, Spain.</p> <p id="par0230" class="elsevierStylePara elsevierViewall">Antonio Zapatero Gaviria: Department of Internal Medicine, Hospital of Fuenlabrada, Madrid, Spain.</p>" "etiqueta" => "Appendix A" "titulo" => "Committee of Standards for Internal Medicine Units" "identificador" => "sec0080" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 928 "Ancho" => 1500 "Tamanyo" => 80440 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Synthetic map of processes of internal medicine units</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviation</span>: PC, primary care.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2220 "Ancho" => 3332 "Tamanyo" => 401666 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Healthcare process for hospitalized patients.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2025 "Ancho" => 3324 "Tamanyo" => 438801 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Healthcare process for complex chronic patients</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviation</span>: PC, primary care.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Abbreviation: IMU, internal medicine unit.</p>" "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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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"><span class="elsevierStyleBold">Process</span> \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"><span class="elsevierStyleBold">Standards</span> \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"><span class="elsevierStyleBold">“Key” processes</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Care for acutely ill patients hospitalized in the Internal Medicine ward</span></span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Admission</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMU team must assess the patient within the first 4<span class="elsevierStyleHsp" style=""></span>h after the patient's arrival in the ward, for those cases in which the patient was not admitted by the on-duty internal medicine team in the medical area. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMU must standardize the communication between practitioners for patient transfers between different care units, avoiding transfers between hospital units. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMU must protocolize and develop clinical pathways for the most prevalent processes and ensure their use from the start of care in the hospital ward. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Follow-up</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMU must assign a medical internist during the hospitalization period, whom the patient should recognize as responsible for their 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="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMU must ensure that the activities described in the National Institute for Health and Care Excellence clinical guideline 50 (NICE 50, Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMU must implement a formal information exchange system and/or conduct multidisciplinary rounds, in which at least the nurses caring for the patient participate. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMU must staff their rooms with sufficient nursing personnel, according to the patient care needs. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Planning the discharge and discharging patients</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMU must standardize the discharge process to ensure the availability of key information regarding the diagnoses at discharge, tests results, treatment plan, precautions and medications. The discharge report must include a medication reconciliation. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The discharge report must contain an action plan that references the therapeutic objectives and clinical follow-up and must be made available to the practitioners responsible for the patient's continuity of care (primary care physician and nurse). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The discharge report must meet the requirements of Royal Decree 69/2015 of February 6, which governs the Recording of Specialized Healthcare Activity. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Support for consulting with primary care and other specialties</span></span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Structure</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMU must establish stable (face-to-face or distance) communication systems with primary care that enables comprehensive 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="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMU must offer stable distance interconsultation systems that can avoid emergency consultations and unnecessary patient transfers. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMU must develop shared follow-up modalities with primary care for chronically ill and complex patients. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The centers’ management must assign workload times for distance consultation and interconsultation activities to promote the periodic displacement of the medical internist to health centers. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Process</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reception \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMU must have prioritization and outpatient pathway criteria, which are agreed upon with primary care, enabling the diagnosis of patients whose condition is rapidly deteriorating or who have unclear and presumably more severe clinical expression within an appropriate time, avoiding as much as possible their hospitalization for the purposes of examination. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Additional care/examinations \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The consultation should include a complete medical history review, systematic examination (not directed) and a request for appropriate examinations. The consultation should create a report when completing the consultation/interconsultation process, with a basic scheme that includes the studies performed, the diagnosis and the plan/treatment to follow. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discharge/Follow-up \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">For complex chronic patients, shared follow-up with the primary care physician is recommended. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Care for complex chronic patients. Continuity of care</span></span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMU must have a structured system for relating to primary care teams of the hospital's area of influence. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">For health areas with more than 100,000 inhabitants, the IMU must have at least one community liaison nurse/case manager assigned. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="9" align="left" valign="top"><span class="elsevierStyleBold">Organization and management</span></td><td class="td" title="table-entry " rowspan="9" align="left" valign="top"></td><td class="td" title="table-entry " align="left" valign="top">Assign someone responsible, with dedication based on the complexity of the healthcare team. \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">Equip the unit with an Organization and Operation Manual. \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">Prepare an Annual Report. \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">Equip the IMU/hospital with a complications recording system. \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">At least twice a year, conduct a multidisciplinary meeting with the practitioners/units that usually collaborate with the unit. \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">Implement a structured system for clinical sessions. \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">Equip the unit with a system of indicators for quality, safety and, as much as possible, results. Conduct their follow-up through a scorecard. \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">Comply with the legal obligations regarding information systems and SEMI registries. \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">Avoid low-value interventions, keeping a list of these interventions updated and available for all unit members to avoid their practice. The abovementioned list should include those interventions that SEMI has indicated should be avoided. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="6" align="left" valign="top"><span class="elsevierStyleBold">Training</span></td><td class="td" title="table-entry " rowspan="2" align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Continuing education</span></span></td><td class="td" title="table-entry " align="left" valign="top">Have a continuing education plan for their members based on the development of professional competencies appropriate for the unit's portfolio of services. \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">Every IMU practitioner must complete at least 40 classroom hours or 4 European Credit Transfer and Accumulation System (ECTS) credits a year. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Graduate Studies</span></span></td><td class="td" title="table-entry " align="left" valign="top">The IMUs accredited for the training of internal medicine specialists must have a training program that includes the minimum requirements. \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">The IMUs accredited for the training of internal medicine specialists must have a teacher for every 5 residents, with time assigned to conduct their work. \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">The IMUs through which the resident physicians rotate from other areas of specialized knowledge must have a training program for these physicians that includes the minimum requirements. \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"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Graduate training</span></span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The IMUs through which undergraduate medical students rotate must have a training program for these students that includes the minimum requirements. \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"><span class="elsevierStyleBold">Research</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Research</span></span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IMUs must have at least one of its members as signatory of a published article in an indexed scientific journal every year. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1604538.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Summary of standards for internal medicine units.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "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=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">Hospitalization</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">Time (min)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Responsibility of internal medicine</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90 \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Daily visit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Discharge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Interconsultation</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>First visit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Successive visits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 \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"><span class="elsevierStyleBold">Consultations</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">Time (minutes)</span> \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Face-to-face</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>First visit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30–40 \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Reviews \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15–20 \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Nonface-to-face</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Episode \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \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"><span class="elsevierStyleBold">Visit to health center</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">120–150</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1604539.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estimated workloads for the various healthcare tasks.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0130" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ministerio de Sanidad, Servicios Sociales e Igualdad. 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| Year/Month | Html | Total | |
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