Article, Emergency Medicine

Outpatient diagnosis and therapeutic units linked with ED referrals: a sustainable quality-centered approach

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Outpatient diagnosis and therapeutic uni”>Correspondence

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: www. elsevier.com/ locate/ajem

American Journal of Emergency Medicine 31 (2013) 1612-1620

Outpatient diagnosis and Therapeutic units linked with ED referrals: a sustainable Quality-centered approach

To the Editor,

We thank Bosch et al [1] for their very important contribution in which they outline how the Quick Diagnosis Units (QDUs) can safely and efficiently avoid emergency department (ED) visits and hospital- izations. They report that, in their institution, in recent years, an increasing number of Primary Care and ED patients were referred to the QDU. Hospitalizations might have been avoided in at least 84% of patients. They conclude that, although QDU and hospitalization are similarly effective in reaching a diagnosis, the QDU model incurs fewer costs. We fully agree with the goals and implementation strategy used by Bosch et al [2] because we share a similar experience working within an Academic University Hospital with excessively long periods of hospitalization, a significant percentage of limited appropriateness of admittance, and an exceedingly high overflow of patients in the emergency division. This pressure is due both to the referral from primary care medical doctors and to the great trust of patients and their relatives to the more reliable effectiveness of EDs. We shifted in the years 2002-2006 part of the patients addressed for full hospitalization by our ED toward a Day Hospital Service (DH). In 2007, we constituted the Diagnostic and Therapy Medical Unit (DTU), with similar criteria with referrals proposed by any of the de- partments of the hospital. The requisites of our unit were and are as follows: an available essential point-of-care laboratory test facility and, more importantly, the certified competence of the medical staff (2 senior and 2 junior medical doctors) in Medical Ultrasonography (US), echocardiography, and dietary/physical exercise assessment and prescription [3] with available onsite facilities. Patient admittance in the DTU was 1890 patients in the years 2009-2012 and 1619 in the preceding years 2006-2008, these last with an exclusive referral from the ED. Considering this group of patients with exclusive ED referrals, the stay in DH was 6.3 +- 3.5 nonconsecutive days, with lower costs per patient and diagnosis in comparison with the costs of longer length of In-hospital stay. In the following years, and currently, only a part of patients is referred by the ED. Overall, patients are referred to the DTU care for secondary anemia (21%), severe malnutrition (including mental anorexia), and heart failure; 27% of patients had a diagnosis of cancer; endoscopy or US-guided biopsies and US-guided Diagnostic procedures were performed in 22% of patients. Imaging and endoscopic facilities are available, with affordable and timely planning schedules. The DTU is a place of training for postgraduate medical doctors of the School of Internal Medicine and of the Postgraduate School of Medical Ultrasound. By these tools, we can provide, in a public hospital, quick and timely morphological diagnosis, by US and Lifestyle assessment, and more articulated therapeutic strategies, including dietary and physical exercise prescription [2]. The model we developed within our hospital is extended to other QDU and mainly Hematology, Nephrology, Cardiology to which, more often than in the preceding years, patients are referred on an outpatient basis for

diagnosis and treatment [4]. These units are reasonably autonomous for US and other specific laboratory diagnosis. The contribution of QDUs, from their progenitors [3,5] to the most actual and well- implemented organizations that are effective in the management of oncologic patients [6,7], is now more recognized than in the recent years. Furthermore, in our opinion, they are mostly important; but we would warrant more medical-quality-centered than medical-accoun- tancy-centered units. Greater focus on staff professional competences in sustainable Diagnostic procedures, such as US is, in our view, a key point for a greater cost-benefit effectiveness for the Patients Health and for the National Health Systems. In any case, such approaches will fasten diagnosis and follow-up of patients often severely ill and will allow sustainable planning of diagnosis and treatment with more focus on personalized medicine [2,4].

Daniela Catalano MD Francesca M. Trovato MD

Clara Pirri MD Guglielmo M. Trovato MD

Medical Diagnosis and Therapy Unit, AOU Policlinico-VE University Hospital of Catania, Catania, Italy E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.07.008

References

  1. Bosch X, Jordan A, Lopez-Soto A. Quick diagnosis units: avoiding referrals from primary care to the ED and hospitalizations. Am J Emerg Med 2013;31:114-23.
  2. Trovato GM, Basile F. Italian Healthcare System in the Global Context: The Cultural Challenge of Predictive, Preventive and Personalized Medicine. In: Golubritschja O, editor. Healthcare Overview. Advances in Predictive, Preventive and Personalised Medicine, 1. Dordrecht: Springer Science; 2012. p. 7-29.
  3. Cosin LZ. The day hospital. Lancet 1953;265:204-5.
  4. Trovato GM. Behavior, nutrition and lifestyle in a comprehensive health and disease paradigm: skills and knowledge for a predictive, preventive and personalized medicine. EPMA J 2012;3:8-23.
  5. Kendall MJ, Toescu V, Wallace DM. QED: quick and early diagnosis. Lancet 1996;348:528-9.
  6. Bosch X, Moreno P, Rios M, Jordan A, Lopez-Soto A. Comparison of quick diagnosis units and conventional hospitalization for the diagnosis of cancer in Spain: a descriptive cohort study. Oncology 2012;83:283-91.
  7. Bosch X, Palacios F, Inclan-Iribar G, et al. Quick diagnosis units or conventional hospitalisation for the diagnostic evaluation of severe anaemia: a paradigm shift in public health systems? Eur J Intern Med 2012;23:159-64.

    Could fear of malpractice contribute to ED crowding?

    To the Editor,

    Clinical practice in the emergency department (ED) is often stressful and fast paced. Ever-increasing patient volumes and crowding in the ED have placed added pressure on physicians to expedite their evaluations and efficiently use limited resources [1,2]. At the same time, there are

    0735-6757/$ – see front matter (C) 2013

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