Complexity in hospital internal medicine departments: what are we talking about?

Abstract

Internal medicine (IM) patients are mostly elderly, with multiple complex co-morbidities, usually chronic. The complexity of these patients involves the intricate entanglement of two or more systems (e.g. body and disease, family-socio-economic and environmental status, coordination of care and therapies) and this requires comprehensive, multi-dimensional assessment (MDA). Despite attempts to improve management of chronic conditions, and the availability of several MDA tools, defining the complex patient is still problematic. The complex profile of our patients can only be described through the best assessment tools designed to identify their characteristics. In order to do this, the Federation of Associations of Hospital Doctors on Internal Medicine FADOI has created its own vision of IM. This involves understanding the different needs of the patient, and analyzing diseases clusters and the possible relationships between them. By exploring the real complexity of our patients and selecting their real needs, we can exercise holistic, anthropological and appropriate choices for their treatment and care. A simpler assessment approach must be adopted for our complex patients, and alternative tools should be used to improve clinical evaluation and prognostic stratification in a hierarchical selection of priorities. Further investigation of complex patients admitted to IM wards is needed.

Are multiple-choice questions a good tool for the assessment of clinical competence in Internal Medicine?

“…First, randomized controlled trials (RCTs) do not reflect the real word of clinical practice: complex patients are often not considered in the admission/exclusion criteria in studies. 36 RCTs are not yet validated assessment tools in distinguishing, when applied, the effects of pre/post training in EBP. Participants are prone to experiencing recall bias, believing that their baseline ability was much poorer than it actually was, therefore increasing their perceived improvement following the training intervention.…”

Variables determining clinical complexity in hospitalized Internal Medicine patients: a workload analysis

“…Overall, mean CIRS-SI was 1.03 (SD=0.31) and median CIRS-CI was 2 (range 1-5) equivalent to a moderate comorbidity. The mean number of diagnoses at discharge was 5.9 (SD=2.3), the median number of clinical tests performed during hospitalization was 8 (range [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18], and the mean number of medications prescribed at discharge was 8 (SD=3.2).…”

“…6 In the setting of Internal Medicine wards, clinical complexity of patients and the varying intensity levels of required care clearly suggests the need for tools to measure activity. 7 Monitoring the workloads of clini- Among different methods of nursing classification, the index of caring complexity (ICC) is a management tool to evaluate appropriateness of nursing procedures, integrate health-care support workers and to monitor the need of nursing staff. Methodology does not require specific data collection but the classification derives directly from the data flow obtained during the caring process as a health/disease continuum.…”

The Niguarda MEWS, a new and refined tool to determine criticality and instability in Internal Medicine Ward and Emergency Medicine Unit

“…Furthermore, the increase in life expectancy has brought with it a kind of fragile patient, multi-pathological, at high risk of complications for comorbidity, and thus in need of intensive care. 4,5 Intensity of care is related to many of these patients' instabilities and critical aspects; hospitalizing internal medicine patients in large wards without prior evaluation of these parameters and without prior risk stratification of rapid clinical deterioration may represent a non-optimal approach. There are limited data in literature about the availability of indicators and scores to attribute the level of intensity care in Internal Medicine.…”