Editorial
Hospital interconsultations: A puzzle to put together
Interconsultas hospitalarias: un puzle por ordenar
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Casariego-Vales, L.A. Cámera" "autores" => array:2 [ 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" => "L.A." "apellidos" => "Cámera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario <span class="elsevierStyleItalic">Lucus Augusti</span>, Lugo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Programa de Medicina Geriátrica, Servicio de Clínica y Medicina Interna, Hospital Italiano, Buenos Aires, Argentina" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Interconsultas hospitalarias: un puzle por ordenar" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">At present, the immense majority of hospitalized patients experience several diseases concomitantly, their frailty has increased, and the healthcare problem has acquired new and worrying dimensions.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Given that the cause of hospitalization is a determinant for deciding the location and responsible department (and is not always the most important problem), there are complex patients hospitalized in all hospital areas and for varied reasons. During hospitalization, complications can also appear that require the participation of other specialties. The care for each of the processes is frequently performed in a fragmented manner, with shortcomings in coordination among the various specialties, like a puzzle whose parts do not always fit well.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The classic established mechanism for hospital collaboration is the interconsultation. Patients who have more than one active medical or surgical problem might require the collaboration of several specialties, thereby resulting in requests for interconsultations with other departments.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> Physicians from various specialties therefore participate in the patient's care, and their interaction is not always simple.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> Due to the fragmentation of the healthcare process, inconsistencies can occur that affect the treatments, diagnostic process, length of stay and readmission rates. From a certain standpoint, this fragmentation-variability relationship is an increasingly frequent structural error in the delivery of healthcare, which mainly affects more complex patients and reduces the quality of care.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The REINA study,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> published in this issue, analyzes the clinical and functional issues of interconsultations conducted with the internal medicine departments of 39 hospitals of 12 autonomous communities in Spain and a hospital in Buenos Aires (Argentina). With this well-defined objective and simple and appropriate research methodology, the study offers data of marked relevance, both clinical and healthcare. With regard to the origin of the interconsultations, more than 80% arise from the surgery departments after the patient has already undergone surgery in most cases. The 5 most common reasons for consultations represent 3 of every 4 consultations and are very common problems in internal medicine wards. A highly relevant fact is that these patients are in a situation of manifested severity. Thus, mortality by the end of the hospitalization (approximately 8%) is practically double that recorded overall for Spanish hospitals.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> Additionally, 15.6% of those discharged to their homes required a subsequent review in internal medicine consultations. The work resulting from this activity is not exactly minor; the initial visit requires as much time as that used by a patient hospitalized in their own bed, only 28.4% of cases are resolved in a single act, and the average follow-up reaches 4.7 days. Lastly, a workload of this caliber and the consequences should be considered in the organization of the department. However, preferential or urgent consultations predominate (2 of every 3 require a response within 24<span class="elsevierStyleHsp" style=""></span>h). The timing of the request is considered inadequate in 21% of the cases (late in 3 of every 4 patients), and verbal contact with the requesting physician was not established in half of the cases. Moreover, the response should not be based on the work of a single physician, because only a cohesive team can ensure the continuity of care that is required.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The description presented by the REINA study<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> shows how the current organization does not cover the actual needs. Decades ago, when interconsultations were isolated requests for advice on a highly specific question, these needs might have been met. At present, however, the increased complexity requires continuous care (average number of visits per patient in this study, 4.7) and makes the interconsulting physician a co-participant in the patient's management.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although the interconsultation could be the connection system for those departments that rarely require support from other areas of the hospital, this study indicates that it is a poor system for those specialties that frequently consult, specialties that treat patients with severe conditions or frequent decompensations. It is important to indicate that perioperative systems for detecting risks help identify the frailest patients, track individual plans and extend their surveillance, all of which have been associated with higher postoperative survival rates.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> All of this supports the fact that well-organized work, with close connections between the responsible physicians improves the quality of care.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> However, the standard system in hospitals in Spain does not include this aspect. In almost half of the cases in the REINA study, the requesting physician and the physician who received the request for interconsultation did not talk with each other.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Another issue to consider is how best to respond to the interconsultations. There are many departments that request support, and each has its peculiarities or type of complications that require understanding. Thus, compartmental syndrome,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> fat embolism<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> and transurethral syndrome<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> are examples related to uncommon procedures or surgical diseases in medical services. To address this demand, we need personnel trained according to the department to which assistance is provided. To this end, some forms of organization need to be changed. As the REINA study noted, more than 50% of the interconsultations were distributed randomly among all department physicians. This healthcare activity arises on demand and is unscheduled, requiring in many cases a comprehensive patient assessment and specific understanding of uncommon medical problems. This activity is also not contemplated in many hospitals’ care systems.</p><p id="par0035" class="elsevierStylePara elsevierViewall">These organizational shortcomings between practitioners and circuits have been detected in numerous systems of many Western countries. The proposed solutions vary depending on the healthcare systems. Some authors point out the benefits of involving “hospitalist” physicians in optimizing perioperative care<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> or in participating through shared care teams.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">12,13</span></a> Others advocate for reorganizing the hospital work,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> while others suggest creating hybrid hospitals with differentiated organizations for the various types of surgical patients.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> Given the differences, we must admit that the ideal model does not exist, although all proposals agree that care based on “internists/hospitalists” is the key. In this “possibilist” line, the Spanish Society of Internal Medicine<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> has recently proposed organizational and operational standards to provide a quality response to this demand. This obviously does not solve all the problems, far from it. However, it structures the work within the internal medicine departments, a key step for organizing the tasks within hospitals.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, based on the data from the REINA study, we can easily appreciate the deficiencies and limitations of outdated organization in hospital departments. We need to consider reorganizing the delivery of services and design new models of care that are appropriate for today's patients. This involves establishing the format, reorganizing the parts, and designing new systems for reconstructing the puzzle, making it as solid as it is effective. This is a basic need for hospitals of the future, and health authorities should sponsor and lead the search for solutions. This initiative would undoubtedly be supported enthusiastically by practitioners and scientific societies.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Casariego-Vales E, Cámera L. Interconsultas hospitalarias: un puzle por ordenar. Rev Clín Esp. 2018;218:293–295.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Characteristics and temporal pattern of the readmissions of patients with multiple hospital admissions in the medical departments of a general hospital" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Matesanz-Fernández" 1 => "R. Monte-Secades" 2 => "I. Íñiguez-Vázquez" 3 => "D. Rubal-Bran" 4 => "H. Guerrero-Sande" 5 => "E. 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