Which surgical patients require shared care?

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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "578" "paginaFinal" => "582" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "E. Montero Ruiz, D. Rubal Bran" "autores" => array:3 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Montero Ruiz" "email" => array:1 [ 0 => "eduardo.montero@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "Rubal Bran" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:1 [ "colaborador" => "For the Shared Care and Consultations Working Group of the Spanish Society of Internal Medicine" ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Qué pacientes quirúrgicos necesitan asistencia compartida?" ] ] "textoCompleto" => "Shared care (SC) is defined as the shared responsibility and authority in managing a hospitalized patient.<a class="elsevierStyleCrossRef" href="#bib0205">1</a> In the scope of surgical specialties, it means that patients hospitalized in a surgical department are attended to by surgeons and, in addition, by internists who carry out the same work as in the internal medicine departments, but in a coordinated fashion with the specialists who are the primary professionals in charge of the patient.<a class="elsevierStyleCrossRef" href="#bib0205">1</a> This entails a profound change in mentality regarding care as well as management that is not easy to achieve.A controversial aspect of SC which generates confusion and problems of all sorts is establishing whether it is necessary to select hospitalized patients in a certain department who would benefit from SC or if, on the contrary, no selection should be made and SC should be provided to all.What type of patients are we talking aboutWhen we refer to surgery patients in general, there is a preconceived notion that a significant percentage of them will have little or no medical complexity. However, the prevalence of cardiovascular risk factors and peripheral, coronary, and cerebral vascular disease has been progressively increasing, already encompassing 50% of surgical patients.<a class="elsevierStyleCrossRef" href="#bib0210">2</a> At least 60% of these patients have significant medical comorbidities, with an even higher prevalence found in the elderly.<a class="elsevierStyleCrossRef" href="#bib0215">3</a> In addition, 68% take five or more drugs on a habitual basis.<a class="elsevierStyleCrossRef" href="#bib0220">4</a>This idea is even further from the truth in hospitalized surgical patients, as scientific and technological advances in all medical and surgical specialties have made it possible to treat patients who are more elderly and with greater comorbidity coupled with the fact that many are not hospitalized or are hospitalized for very short periods of time. According to data from the Ministry of Health,<a class="elsevierStyleCrossRef" href="#bib0225">5</a> between 2010 and 2017, the percentage of major outpatient surgery rose from 39.8% to 46.4%. Some examples of these advances are hip and knee arthroplasty<a class="elsevierStyleCrossRef" href="#bib0230">6</a> or the extirpation of brain tumors,<a class="elsevierStyleCrossRef" href="#bib0235">7</a> which are now being performed as outpatient procedures in some hospitals. As a result of this progress, the age and complexity of hospitalized patients are increasing,<a class="elsevierStyleCrossRefs" href="#bib0240">8,9</a> and fast. In just four years, between 2012 and 2016, the age of patients hospitalized in a Spanish hospital increased by 4.7% and the Charlson Comorbidity Index by 34.7%.<a class="elsevierStyleCrossRef" href="#bib0250">10</a> This may be one of the reasons why an increase of 100% in complications occurring in surgical patients is expected over the next two decades.<a class="elsevierStyleCrossRef" href="#bib0255">11</a>In 2018, the surgical departments of the Ramón y Cajal University Hospital (Madrid) discharged 14,079 patients aged greater than or equal to 16 years. Of them, only 14,888 (10.6%) were younger than 40, had four or fewer discharge diagnoses, and a Charlson Comorbidity Index of less than three.It should be underscored that in our experience, a significant percentage of these “not very sick” patients have infections, which must be taken into account given that the majority of surgeons do not manage antibiotic therapy with sufficient confidence and delegate this task to residents or other specialists.<a class="elsevierStyleCrossRef" href="#bib0260">12</a> These data are in accordance with those from the only published work on surgical patients who may be good candidates for SC, which indicates that at least 90% of them should be attended to through SC.<a class="elsevierStyleCrossRef" href="#bib0265">13</a> One exception is patients hospitalized in obstetrics departments, as the vast majority do not have comorbidities; thus, perhaps patients who would benefit from SC should be selected in this case.Currently, we can affirm that a large part of hospitalized surgical patients have a high comorbidity burden and receive a large number of medications, have significant complications, or both.Patient selectionIn surgical departments, there is always a percentage of patients—probably the majority according to what is indicated in the preceding section—who would benefit from SC. The problem lies in knowing which they are. To be able to identify them, the selection system must be clear and easy to use. However, the different criteria that could be used for this selection are not sufficiency efficacious or simple; all exclude a significant number of patients who could benefit from SC.Some selection criteria that could be used are:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Upon demand by the surgical specialist. This is the same system used in a traditional consultation. Multiple problems inherent to this system are already known. In this case, of special importance is the mechanism for launching the process,<a class="elsevierStyleCrossRef" href="#bib0270">14</a> which is a factor that dissuades against its use.</li><li class="elsevierStyleListItem" id="lsti0010">-Age. This criterion is easy to apply and used particularly among geriatric patients, but differentiates poorly for risk and surgical prognosis. For this task, comorbidities, medical history, and the type of surgery are much more important factors.<a class="elsevierStyleCrossRef" href="#bib0275">15</a> More than 50% of patients younger than 65 years of age have multimorbidity.<a class="elsevierStyleCrossRef" href="#bib0280">16</a></li><li class="elsevierStyleListItem" id="lsti0015">-Disease. A common example is hip fractures. In this case, the results would be very good because patients would be clearly selected, but it is evident that a large number of patients who may also benefit from SC would be excluded.<a class="elsevierStyleCrossRef" href="#bib0285">17</a></li><li class="elsevierStyleListItem" id="lsti0020">-Type of admission (emergency/scheduled). This criterion is very easy to apply. It is easy to believe that patients with scheduled surgery would not need SC as they are clinically stable and have been evaluated in a prior anesthesia consultation. However, at least 30% of cancellations of scheduled surgeries are due to medical problems.<a class="elsevierStyleCrossRef" href="#bib0290">18</a> At least one third of scheduled patients have anemia and many more are iron deficient.<a class="elsevierStyleCrossRef" href="#bib0295">19</a> Another third have medication errors upon admission.<a class="elsevierStyleCrossRef" href="#bib0300">20</a> Up to 67% present with medical complications.<a class="elsevierStyleCrossRef" href="#bib0305">21</a> Perhaps for this reason, more than 60% of patients who undergo a scheduled colectomy or hip replacement have at least one medical consultation.<a class="elsevierStyleCrossRef" href="#bib0310">22</a> Indeed, 30% of consultations requested by general surgery departments are for scheduled patients.<a class="elsevierStyleCrossRef" href="#bib0315">23</a> These facts help explain why good results are being published on SC in scheduled colorectal surgery<a class="elsevierStyleCrossRef" href="#bib0320">24</a> or in elective arthroplasty.<a class="elsevierStyleCrossRef" href="#bib0325">25</a> In addition, this type of selection may give rise to the paradox of selecting a 20-year-old patient with no medical history of any kind who is admitted for emergency surgery yet not selecting an 80-year-old patient with a lengthy medical history who takes a large number of medications but who is admitted for scheduled surgery.</li><li class="elsevierStyleListItem" id="lsti0025">-Selection of high-risk patients. Another system that has been attempted to be applied is selecting patients who are high-risk for the surgery. Whereas in other areas of medicine the medical record and physical examination are fundamental to a patient's care, in the evaluation of surgical risk, substituting them with risk calculators that are easy for the surgeon or anesthesiologist to use has been attempted.<a class="elsevierStyleCrossRef" href="#bib0330">26</a> However, none of the existing calculators can fully predict a patient's individual risk. All leave out clinical data that are important for surgical prognosis.<a class="elsevierStyleCrossRef" href="#bib0330">26</a></li><li class="elsevierStyleListItem" id="lsti0030">-Other criteria/systems. It has also been attempted to combine these and other criteria using new technology such as artificial intelligence and Big Data in order to identify patients with increased surgical risk. Even the best predictive models that have been developed have not achieved this objective well enough for them to be used routinely.<a class="elsevierStyleCrossRef" href="#bib0335">27</a></li></ul>Even if we find a good selection system, how do we know if a patient meets or does not meet the established criteria? For this, the medical record taken by the corresponding specialist must be used. It is clearly defined and recommended that the specialist consulted, when responding to a consultation, must personally verify the available information and complete it, if applicable.<a class="elsevierStyleCrossRef" href="#bib0340">28</a> This recommendation is fully applicable in SC and obligates the internist to personally evaluate each patient hospitalized in the surgical department both from a clinical point of view and in terms of their functional, mental, and social condition.If evaluating all these hospitalized patients may seem like it would generate a significant volume of work with little clinical value, reality shows that this is not the case. We have already seen that hospitalized surgical patients are medically very complex. At first glance, it seems that internists limit ourselves to maintaining patients stable with other means that we perceive as vital (management of fluids, nutrition, etc.), but which also have a big impact on outcomes. We must also take into account that one of the fundamental purposes of SC is to avoid complications from occurring or detecting them early at all costs. To do so, it is necessary to be present in the surgical wards.Failure to rescueTo improve outcomes in surgical patients, the preoperative risk evaluation and prevention of postoperative complications have been the subject of much attention. In addition to this, there is growing interest in the opportunity afforded by appropriate care of postoperative complications in due time and form for decreasing postoperative mortality.<a class="elsevierStyleCrossRef" href="#bib0345">29</a> Some works indicate that a lower rate of perioperative complications is not necessarily related to a reduction in postoperative mortality<a class="elsevierStyleCrossRefs" href="#bib0350">30,31</a>; a lower mortality rate has even been observed in hospitals with higher rates of complications.<a class="elsevierStyleCrossRefs" href="#bib0350">30,31</a> This finding could mean that perioperative management is what makes the difference in postoperative mortality.<a class="elsevierStyleCrossRef" href="#bib0355">31</a>Failure to rescue is defined as in-hospital mortality secondary to postoperative complications.<a class="elsevierStyleCrossRef" href="#bib0360">32</a> It is considered a robust measurement of quality of care because it reflects hospital quality in the care of patients who develop postoperative complications<a class="elsevierStyleCrossRef" href="#bib0355">31</a> and is the principal factor behind the variation in in-hospital surgical mortality.<a class="elsevierStyleCrossRef" href="#bib0355">31</a> It is an especially important concept given that it can affect any patient regardless of age, comorbidity, or type of surgery.In a study on “healthy” patients (American Society of Anesthesiologists [ASA] physical status classification 1–2), including outpatients, in which the perceived risk of negative outcomes was practically nonexistent, 30-day mortality was 0.7‰; 7‰ had sepsis, severe sepsis, or septic shock; and 0.7‰ had a stroke or myocardial infarction.<a class="elsevierStyleCrossRef" href="#bib0365">33</a>Medical comorbidity is a much more important risk factor than age for surgical prognosis.<a class="elsevierStyleCrossRef" href="#bib0370">34</a> Medical complications are related to at least 80% of operative deaths,<a class="elsevierStyleCrossRef" href="#bib0305">21</a> and 72% of readmissions of surgical patients are due to medical reasons.<a class="elsevierStyleCrossRef" href="#bib0375">35</a> In neurosurgery, a direct relationship has been observed between failure to rescue and medical and infectious complications, but not with neurosurgical complications. This seems to indicate that among the different hospitals, what fails is the medical care, not the neurosurgical care.<a class="elsevierStyleCrossRef" href="#bib0380">36</a>In failure to rescue, different characteristics of the hospital come into play, including the beds-to-nurse ratio, the volume of activity in the hospital, and medical training.<a class="elsevierStyleCrossRef" href="#bib0350">30</a> This last aspect is of vital importance, given that as we stated above, hospitalized surgical patients have a high medical comorbidity that is outside the scope of surgeons’ training and skills. Experience in managing patients with medical diseases is fundamental to the quality and cost of the care provided.<a class="elsevierStyleCrossRef" href="#bib0385">37</a>One explanation of this problem is that surgeons’ care in emergencies that may arise may be insufficient. Having such deep knowledge of their specialty yet more and more limited knowledge outside of it limits their capacity to detect and treat emergencies that are not in their field,<a class="elsevierStyleCrossRef" href="#bib0390">38</a> which triples the risk of suffering from adverse events in the hospital.<a class="elsevierStyleCrossRef" href="#bib0390">38</a>For all of the above, it is unsurprising that the most important factor among the hospital characteristics that most drastically reduces failure to rescue is the presence of internists in surgical wards,<a class="elsevierStyleCrossRef" href="#bib0395">39</a> with on-call physicians also playing an important role in reducing postoperative mortality.<a class="elsevierStyleCrossRef" href="#bib0400">40</a>Organization of careAn important aspect is that if SC is expanded to include all hospitalized patients, the organization of care and analysis of results would be greatly simplified and the work of nurses, surgeons, and internists would be facilitated.ConclusionThe arguments and comments stated in this article allow us to affirm that all patients hospitalized in surgical departments should receive SC. It is evident that the staff of internists needs to be increased. This is not an objective that can be reached immediately, but it is possible over the medium- or long-term.Conflicts of interestThe authors declare that they do not have any conflicts of interest." 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Shared care (SC) is the shared responsibility and authority in managing hospitalized patients. In this article, we discuss whether patients should be selected for SC or not. The various selection criteria are not an exact science nor are they easy to apply. Furthermore, they may leave out many patients who may be good candidates for SC. Perioperative management is essential for preventing postoperative mortality. Failure to rescue (in-hospital mortality secondary to postoperative complications) is the main factor linked to in-hospital surgical mortality and can affect any patient regardless of age, comorbidity, or type of surgery. The component that most reduces failure to rescue is the presence of internists in surgical wards. We believe that all patients hospitalized in surgery departments should receive SC." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La mayoría de los pacientes quirúrgicos hospitalizados tiene mucha comorbilidad médica y recibe un gran número de medicaciones, o sufre complicaciones importantes, o ambos. La asistencia compartida (AC) es la responsabilidad y autoridad compartidas en el manejo de un paciente hospitalizado. Se discute si se deben seleccionar o no pacientes para la AC. Los diferentes criterios de selección no son seguros o fáciles de aplicar, y dejan fuera a muchos pacientes subsidiarios de AC. El manejo perioperatorio es fundamental para la mortalidad postoperatoria. El fallo del rescate (mortalidad hospitalaria secundaria a complicaciones posquirúrgicas) es el principal factor sobre la mortalidad quirúrgica hospitalaria. Afecta a cualquier paciente, independientemente de su edad, comorbilidad o tipo de cirugía. El componente que reduce más el fallo de rescate es la presencia de internistas en las salas quirúrgicas. Consideramos que todos los enfermos hospitalizados en los servicios quirúrgicos deberían recibir AC." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Montero Ruiz E, Rubal Bran D. ¿Qué pacientes quirúrgicos necesitan asistencia compartida? Rev Clin Esp. 2020;220:578–582." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:40 [ 0 => array:3 [ "identificador" => "bib0205" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asistencia compartida (comanagement)" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "por el Grupo de Trabajo de Asistencia Compartida e Interconsultas de la Sociedad Española de Medicina Interna (SEMI)" "etal" => false "autores" => array:1 [ 0 => "E. 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