Surgery is scheduled. However, the patient who must be operated on is particularly complex. And if custom leads to requesting specific advice, perhaps from an internist, to understand how far and how the operation can be carried out while limiting the risks, in the future there will increasingly be an expert who integrates into the team that uses the scalpel.
What makes him think is the figure of the Hospitalist, destined to be increasingly present in organizational models, as part of a new model of hospital healthcare that goes beyond simple specialist consultancy, becoming an active and integral part of the surgical team.
What is it about? And what experiences are there? The experts spoke about it on the occasion of the National Congress of the Italian Society of Internal Medicine (SIMI). Among the speakers also Ombretta Para, Medical Director of Internal Medicine at the AOU Careggi in Florence, where she works as a hospitalist in Emergency Surgery and Neurosurgery.
What does the Florence model propose?
The model adopted since 2010 in the Florence hospital is pioneering for our country and is inspired by European and American models, despite presenting specific organizational differences. In the company, the fundamental implication of co-management sees the overcoming of the consultancy model: the hospitalist is able to manage the complex patient in a surgical context, thanks to transversal skills and specific soft skills. In this way, the hospitalist is an active part of the patient’s entire clinical path, perfectly integrated into the surgical team through participation in the joint visit with the surgeons and in briefings, such as with the neurosurgeons. This integration is considered the real novelty and added value.
But it’s not enough. Since 2018 there has been a PDTA (Diagnostic Therapeutic Assistance Path, a clinical and organizational governance tool that defines the optimal treatment path for patients with specific pathologies or health needs) structured in emergency surgery, as well as a plan shared between specialists for the management of complex patients. These are two decisive steps according to the expert. The model allows each figure to play an active role through the enhancement of specific skills. By virtue of the shared plan, the hospitalist has access to the medical record and can define diagnostic paths and therapeutic changes to share with others.
“We had the opportunity to integrate the internist into the surgical team. This gives the possibility, for example, of visiting together with the surgeons and participating in the briefing with the neurosurgeons, going beyond the consultancy model”
Para explains.
Attention to the complex patient
The hospitalist’s activity consists in taking charge of the complex patient and coordinating the entire treatment process:
“In the surgical setting this means, in the pre-operative phase, preventing possible complications, optimizing the treatment of chronic pathologies and intercepting complications early in the post-operative phase”
continues the doctor.
The approach has led to positive results, such as the reduction in hospitalizations and mortality due to internal medicine problems. The studies published on the model adopted at Careggi in Florence show favorable results in terms of reduction in the number of internal medicine consultations, new hospitalizations and mortality due to internal medicine problems. In particular, a work published last April in the journal Internal and Emergency Medicine, of which Para is the first author, demonstrated the effects of implementing the hospital co-management program in the neurosurgery department of the Florentine hospital. Co-management by hospitalists was associated with a reduced incidence of medical complications, 30-day hospital readmissions, and number of ICU transfers or with a high rate of satisfaction among healthcare providers.
Experimentation in Lombardy
Hospitalist experimentation has also started in two departments at the IRCCS Fondazione Ca’ Granda Ospedale Maggiore-Policlinico Università di Milano. Introduced in September for neurosurgery and previously in May for traumatology, the initiative initially sees the hospitalist operate as a permanent consultant, present in the morning from Monday to Friday. The future objective will be complete, 24-hour management of patients by the internist, freeing surgeons from department tasks and concentrating them on surgical procedures.
“In traumatology, for now one of our doctors acts as a permanent consultant for reported cases which mainly concern femur fractures, infections or prostheses. In the future, however, it is expected that the internal specialist will take charge of patients 24 hours a day and discuss management with other specialist doctors”
explains Giorgio Costantino, Associate Professor of Internal Medicine, Director of Emergency Room and Emergency Medicine at the IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico – University of Milan.
Among the expected outcomes there is a reduction in complications and management times together with greater patient and operator satisfaction. The introduction will be completed when internal medicine doctors will be able to manage trauma patients 24 hours a day, from admission to the emergency room until the continuation of the process with the indication, for example, of a rehabilitation path.
“Despite being highly specialized, orthopedists and neurosurgeons often find themselves having to manage elderly and multi-pathological patients. For these patients, who are fragile and have a precarious clinical balance, a solely surgical management is not sufficient. This approach would instead allow orthopedists and neurosurgeons to concentrate on the interventions that are the heart of their profession, delegating the complex medical management of the patient to the internist. At the same time, the internist would have the opportunity to treat a different type of patient than usual, finding satisfaction in the resolution of medical problems which, although not the primary cause of hospitalization, are fundamental for the success of the operation. I think the approach can lead to a win-win for everyone”
concludes Professor Costantino.
