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Can we humanize care in hospital medicine?
¿Podemos humanizar la asistencia en la medicina hospitalaria?
L.A. Sánchez-Muñoz
Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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"tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "280" "paginaFinal" => "281" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "L.A. Sánchez-Muñoz" "autores" => array:1 [ 0 => array:3 [ "nombre" => "L.A." "apellidos" => "Sánchez-Muñoz" "email" => array:1 [ 0 => "lsanchezmunoz@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Podemos humanizar la asistencia en la medicina hospitalaria?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years, the humanization of care has been gaining importance and has been incorporated in the strategies of health services and of a number of scientific societies.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1–3</span></a> The humanization of care requires a commitment by managers and health professionals to humanize the relationships, behaviors, environment and operation, placing patients as the subject, not the object, of attention.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a> Numerous barriers have been reported that hinder humanized care (patient load, bureaucracy, modernization, delays, fragmentation of care).<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a> Citizens demand comprehensive, accessible, patient-focused care, with continuity and quality of care, clear information and a personalized plan, with special care in situations such as birth and death and for this care to be offered in a comfortable environment.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,4</span></a> Hospitalization is a vulnerable experience both for the patient and their relatives. Facilitating more humane care can promote patient recovery and achieve greater satisfaction and perceived quality.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> We therefore need to review a number of areas needing improvement in the humanization of hospital care.</p><p id="par0010" class="elsevierStylePara elsevierViewall">1. <span class="elsevierStyleItalic">Improvement in patient wellbeing during hospitalization and prevention of posthospitalization syndrome</span>. There are numerous factors during hospitalization that contribute to patient discomfort: sleep disorders, dietary deficiencies, pain, drugs that alter the cognitive state, immobility, implementation of procedures, isolation and loss of autonomy and privacy.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> A significant number of patients therefore present pain, weakness, malnutrition, pressure ulcers, sleep disorders, cognitive impairment, anxiety and depression after being discharged.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3,5</span></a> This negative effect of hospitalization, known as posthospitalization syndrome, is the reason for two-thirds of readmissions and shows that care should not be focused only on the primary diagnosis but rather on the individual as a whole (especially for frail patients).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> This overall approach is facilitated by tools such as the comprehensive geriatric assessment (which includes clinical, functional, cognitive-affective and social-familial aspects), whose use has been shown to reduce hospital mortality and readmissions in a meta-analysis of 22 clinical trials.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Improving patient wellbeing is our issue,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> because the negative effect of these problems on the patient's quality of life and health outcomes has been demonstrated. To this end, transversal practices have been proposed for the care of hospitalized patients, most of which agree with those described for preventing delirium and confusion<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3,7,8</span></a>: avoid sensory isolation (glasses and hearing aids), provide reorientation measures (extended family company, calendar, watch, natural light, personalization of the space), reduce sleep interruptions (care schedules and reduced environmental noise), minimize pain and stress, promote good nutrition and address the nutritional deficits (adjusted diet, intake control), enable early mobilization (withdrawal of catheters and probes, avoid bed-confinement and restraints), encourage physical activity, patient autonomy (ambulation, toilet) and entertainment (reading, radio, TV) and optimize the use of sedatives.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">2. <span class="elsevierStyleItalic">Improvement in family accessibility and accompaniment</span>. The organization of care and family visits for hospitalized patients is, to a large extent, aimed at facilitating the practitioner's tasks, assuming that this would favor improved patient care. Allowing and even encouraging the presence of a companion for the patient, if possible, in all healthcare settings but especially for pediatric patients and patients with cognitive impairment, is a safe practice recommended by the Spanish Ministry of Health, Social Services and Equality,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> helps patients remain oriented and can contribute to reducing the stress created by hospitalization in patients and their relatives.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3,8</span></a> Over the last few years, there have been initiatives on this issue (flexible schedules, “open door” policies in intensive care units), which have shown benefits for patients, relatives and practitioners.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">3. <span class="elsevierStyleItalic">Improvements in communication with patients and relatives</span>. Communication is a basic tool in health care that, in addition to appropriately and respectfully informing patients and relatives, requires listening, understanding and getting involved.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Communication is improved by identifying the physician responsible, providing appropriate schedules and physical spaces (with certain flexibility) and using leaflets and written information as support for shared decision-making.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">4. <span class="elsevierStyleItalic">Participation of relatives in the patient's care</span>. The possibility of interfering with the implementation of procedures and in the healthcare team's dynamic is often a barrier that hinders putting this participation into action.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Providing relatives with instructions and supervision so that they can participate in the care (feeding, mobilization, hygiene) can have positive effects on the patients, relatives and practitioners by improving communication among those involved.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">5. <span class="elsevierStyleItalic">Improving the care at the end of life</span>. Protocolization of palliative care is necessary for a comprehensive approach of patients and relatives, considering their preferences (advanced directives, limitation of life support techniques) and physical (protocol for symptom control and sedation), emotional and spiritual needs, facilitating accompaniment (individual room, 24<span class="elsevierStyleHsp" style=""></span>h visiting hours), assisting in the subsequent administrative processes and identifying pathological grief.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">6. <span class="elsevierStyleItalic">Humanizing the areas of hospitalization</span>. The physical work environment influences the physical and psychological state of patients, relatives and practitioners and affects the healthcare results.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a> Although this issue is more developed in intensive care and pediatric units, it can also be applied to conventional areas of hospitalization, by improving the environmental conditions (natural light, furniture, temperature, noise), privacy (individual room, screens/curtains, information room), orientation (visible window, calendar and watch), entertainment (TV, radio, telephone), signage and accessibility (keypads, switches, railings, etc.) and comfort in the family area (appropriate furniture in the living rooms).<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In summary, humanization of health care is more than having comfortable facilities and friendly treatment. Humanization requires that we humanize the relationships (communicate more than information), behaviors (promote nutrition, early mobilization and patient autonomy, ensure nocturnal rest, minimize pain and the use of sedatives), the physical environment (improving hospitalization areas) and their operation (accessibility, family accompaniment and participation in care).</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: Sánchez-Muñoz LA. ¿Podemos humanizar la asistencia en la medicina hospitalaria? Rev Clin Esp. 2019;219:280–281.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Análisis de situación de los aspectos humanísticos de la atención sanitaria en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Zarco" 1 => "B. Ruiz" 2 => "B. Barragán" 3 => "J. Ancochea" 4 => "A. Franco" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2017" "editorial" => "Fundación HUMANS" "editorialLocalizacion" => "Madrid" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0055" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Plan de Humanización de la Asistencia Sanitaria 2016-2019" ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2016" "editorial" => "Dirección General de Coordinación de la Atención al Ciudadano y Humanización de la Asistencia Sanitaria, Consejería de Sanidad" "editorialLocalizacion" => "Comunidad de Madrid, Madrid" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0060" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Manual de buenas prácticas de humanización en Unidades de Cuidados Intensivos" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "Grupo de trabajo de certificación de Proyecto HU-CI" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2017" "editorial" => "Proyecto HU-CI" "editorialLocalizacion" => "Madrid" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0065" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Por una medicina interna de alto valor" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Varela" 1 => "A. Zapatero" 2 => "R. Gómez-Huelgas" 3 => "A. Maestre" 4 => "Díez-Manglano" 5 => "R. Barba" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:2 [ "fecha" => "2017" "editorial" => "Sociedad Española de Medicina Interna" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0070" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Post-hospital syndrome. An acquired, transient condition of generalized risk" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H.M. Krumholz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "N Engl J Med" "fecha" => "2013" "volumen" => "368" "paginaInicial" => "100" "paginaFinal" => "102" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0075" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomized controlled trials" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Ellis" 1 => "M.A. Whitehead" 2 => "D. Robinson" 3 => "D. O’Neill" 4 => "P. Langhorne" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bmj.d6553" "Revista" => array:5 [ "tituloSerie" => "BMJ" "fecha" => "2011" "volumen" => "343" "paginaInicial" => "d6553" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22034146" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0080" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rehabilitation is part of medicine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. Oliver" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "BMJ" "fecha" => "2016" "volumen" => "352" "paginaInicial" => "i270" "itemHostRev" => array:3 [ "pii" => "S0140673606692908" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0085" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Delirium in hospitalized older adults" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E.R. Marcantonio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMcp1605501" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2017" "volumen" => "377" "paginaInicial" => "1456" "paginaFinal" => "1466" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29020579" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0090" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Estrategia de Seguridad del Paciente del Sistema Nacional de Salud. Período 2015-2020" ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:2 [ "fecha" => "2015" "editorial" => "Ministerio de Sanidad, Servicios Sociales e Igualdad" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/22548874/0000021900000005/v1_201905300945/S2254887419300827/v1_201905300945/en/main.assets" "Apartado" => array:4 [ "identificador" => "71813" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Correspondence" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22548874/0000021900000005/v1_201905300945/S2254887419300827/v1_201905300945/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419300827?idApp=WRCEE" ]
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