CentralPatient Admissions

Transcription

1 new task and challenge for sonography CentralPatient dmissions K.Seitz,M.Mauch and D.Vasilakis In Germany, acomprehensive reimbursement system designed around Diagnosis Related Groups (DRGs) was introduced following the Health Reform ct of The previous method of payment, wherein the number of treatment days was multiplied by the amount allowed per treatment day, was discarded. The new DRG-based payment system requires the optimization of patient treatment,from admission to discharge, in order to secure the income the hospitals need to survive. The structure of CentralPatient dmissions n important step is the introduction of acentral Patient dmissions (CP) unit. The CPis interdisciplinary and all organizational and diagnostic features are available to all participating medical specialties. In this organizational unit various processes - depending on the size of the hospital - are integrated and streamlined. The administrative functions of the CP and initial medical treatment are concentrated in one place, which saves both personnel and costs and expedites patient treatment.asic treatment level hospitals (for surgery,internal medicine and gynaecology) only need one centraladmissions location. Ifpossible,ambulances should be integrated with, or are attached to, the CP (Fig. 1). In larger clinics, several medical departments can also join to operate a single CP. This is particularly usefulbecausemany patients arrive without being assigned to any specific medical department -or they arrive having been assigned to Fig. 1: CP principle: shortest possible distances Shock room Medical history Examination Monitoring Decision-making Lab Ultrasound X-Ray /CT dmin. /Secreteriat Waiting area Short-term patients 28

2 Some 70%of patients not having trauma or without a specific reason for hospital treatment suffer from problems related to internal medicine Patient Gyn Urol ECG Formal admission/ blood test CP Nurse Psych Medical history Triage Clinical examination Internal medicine Shock room naesthetist Neurology Stroke unit X-ray/ CT Sonography bdomen Heart Vessels Surgery OR Endoscopy ICU Coronary Outpatient treatment Short-term patients Regular ward Fig. 2: Structure of Central Patient dmissions the wrong one. single CP can easily be organized to serve internal medicine, surgery, psychiatry and urology (Fig. 2). The way acp is structured is less a question of the number of medical departments involved than of the departments ability to cooperate and of the spatial arrangement of the clinics.n alternative to a single CP is a close meshing of CP, surgical outpatient department and possibly the insurance companies emergency medical services. This alternative also requires that the units be located close to one another. Since internal medicine cases predominate, ideally a clinically very experienced internist, who can quickly call on colleagues from other disciplines if needed, should head the CP. Cooperation issues among the various disciplines should be resolved in a spirit of partnership and collegiality. The surgical first treatment of accidents is easy to determine and is best offered on site. Fron an organizational point of view it is very important that a shock room or a reanimation room be available and that it be physically located near the radiology department. The CP should be attached toa regular ward or to a wardfor short-termpatients. 24/7 staffing of the CP with a physician and nurses is an absolute must for the unit to function properly.the size of the CP and the number of its staff is determined by the number of patients tobe treated. The goal is to treat the patients quickly and competently within a specified period of time. s a rule, one to two hours is the accepted maximum time apatient should remain in the CP Emergencies have to be treated immediately and the patients who are most ill should, after initial treatment,be quickly transferred to the ICU or to the stroke unit.ifapatient obviously requires inpatient treatment, he or she has to be transferred to the appropriate department immediately following initial treatment. In most cases, it must be determined whether outpatient treatment will sufficeor if inpatient treatment is required. Occassionally it is not clear to which department the patient should be Income Costs Profit Deficits Reducing length of stay Fig. 3:The graph shows that the first days of the hospital stay are crucial,not only in terms of medical success,but also in terms of economic success. assigned, therefore an experienced clinician must be available. Taking the medicalhistory,clinical examination, basic laboratory tests, resting ECG, sonography and, if needed, chest x-ray can be completed in minutes which means on the basis of these procedures and in this timeframe the next steps can be determined, especially whether inpatient or outpatient treatment is required. y providing competent clinical services at the time of admission,patients won t be admitted to the wrong departments and diagnostic blind alleys can be largely avoided. This translates directly to cost reductions and shortened length of stay (Fig. 3). y staffing the CP with a junior doctor/intern and providing him or her with the ability toconsult with a directly available CP supervisory physician, the CPprovides an ideal opportunity for training of junior medical staff. The staffing of this position is of utmost importance for the effective functioning Costs Income 29 Length of stay

3 Fig.4:Thisdiagramhas remained moreor less unchanged since the 1970s.asically,all depicted emergency diagnoses can be easily recognized by sonography. From Internistische Differentialdiagnose by Hegglin. Fig. 5: Very small gallstones 30 of an internal medicine department or clinic.it is just as important as having an excellent endoscopic physician or invasive cardiologist on site. Profile of the CPhead The ideal candidate for the position as CPhead is an internal medicine generalist with very good knowledge of emergency medicine. crucial aspect is his/her training and experience in clinical sonography since noother procedure non-invasively provide such a wealth of diagnostic information in such a short period of time. Clinical sonography is important since effectively realizing the potential of sonography requires clinical knowledge. His or her sonographic skills should cover the abdomen, retroperitoneum, thorax and soft tissues as well as the heart and blood vessels because the clinician must deal with problems from for aortic stenosis tozfor zygomatic tumor. Even if he or she does not master all sonographic techniques equally, with the exception of abdominal sonography, sonographicdiagnosticexpertise is indispensable -if a routine one stop shopping via CTisn t to entirely replace the internist and sonography. Sonography as the central interfaceofacp The purpose of a CP is to avoid high transportation costs and long waiting times. Therefore,ahighquality ultrasound system equipped with colour Doppler and three transducers is required. curved array is necessary for the abdomen, retroperitoneum, and thorax,aphased array is needed for echocardiology, and ahigh resolution 7 MHz transducer is needed for diagnostics on small parts,blood vessels and intestines to definitively answer the frequent questions about appendicitis and diverticulitis. The system should be mobile and the electronic format of the findings documentation must be HIS-compatible. Its use in rooms lit by daylight demands additional measures for darkening the room; if this is not possible, the stationary useof ultrasound diagnosticequipment is preferred. Diagnostics of the abdomen and retroperitoneum Especially in diagnostics related to emergency medicine, upper abdominal sonography is indicated for all abdominal and retroperitoneal conditions or

4 Fig. 6a: pproximately 6 cm cyst in an 11-year old boy, right lateral to the head of the pancreas in close relationship to the duodenum. Fig. 6b: With the 5 MHz transducer 2 cup-shaped wall layers lying atop one another can be differentiated: V.a.duodenal duplication (surgically verified). Fig. 7a: Patient with upper abdominal pain and known Crohn s disease: tubular echo-free structure towards the gall bladder. Fig. 7b: Colour Doppler sonography:collateralblood vessels withanold thromboticblockage of the superior mesenteric vein. Fig. 8: Hepatocellular carcinoma(hcc) withhemochromatosis complaints to prove or to rule out an illness (Fig. 4). Gallstones (Fig. 5), pancreatitis, icterus, urinary blockages, and urolithiasis are important. Frequent questions apply to appendicitis and diverticulitis.in an emergency situation,free gastrointestinal perforations, ileus, and aortic aneurysms are important conditions that can be sonographically clearly confirmed or ruled out. Many diseases can be immediately treated by the appropriate medication or surgical therapy without additionaldiagnostics.in many cases,for example in oncological problems, the tumour is detected on the day of admission, e.g. liver metastasis, pancreatic cancer, lymphomas, lymph node metastasis, and extraorganic space invading processes. Early sonography is moreand more frequently the decisive diagnostic measure used to diagnose rare diseases (Figs. 6, 7, and 8). 31

5 Fig.9aand 9b: Rare NC-negative vasculitis of the superior mesenteric artery in a40-year old female patient with upper abdominal pain. K.Seitz,M.Mauch and D.Vasilakis Department of InternalMedicine cademicteaching Hospital of the University of Tübingen Hohenzollernstraße Sigmaringen Germany 32 Thorax and heart Pleura effusions ( white hemithorax ) and illnesses of the thorax wall including ribfractures are frequent questions to which sonography can provide clear answers. Echocardiographic diagnosis of limited left ventricular function, the dilation of the right ventricle in lung embolisms, proving or ruling out pericardial effusion, dilative cardiomyopathy, and left heart hypertrophy, measurement of pulmonalarterial pressure in triscuspidalinsufficiency, recognition of important valve anomalies are diagnoses that are basically certainly not reserved only for cardiologists with completed specialized training. Moredifficult toassess aredisturbances toheart wall motion that occur during heart attacks.in suchcases, anecg and troponin test are the procedures of choice. The cardiologist, however, should be consulted to determine a thoracic aortic aneurysm or endocarditis by using transesophageal echocardiography. lood vessel diagnostics Diagnostics of the blood vessels in acp is primarily limited to the verification or ruling out of venous thromboses and acute arterial blockages.the example depicted below of vasculitis of the superior mesenteric artery is certainly rare (Fig. 9). Without sonography this diagnosis would not have been made this early,because there was no indication present for an imaging of the blood vessels. Summary The CP is an ideal instrument for diagnosing and treating patients more effectively and economically. dmission procedures have to be tightly organized. clinically competent and organizationally proficient physician who is highly teamworkoriented should head the CP.Immediately available ultrasound diagnostics is the most important diagnostic tool for achieving the desired economicoutcome. In particular, the number of cases where patients are being sent to the wrong medical department can be significantly reduced. Moreover, a well functioning CPcancontributeconsiderably to the training of young doctors sincedue to the introductionofdrgs they will no longer be able to encounter many diseases under inpatient conditions.