domingo, 17 de agosto de 2014

Hospitalistas estiveram reunidos no Rio de Janeiro

O evento ocorreu junto ao Safety, organizado anualmente na cidade maravilhosa, desde 2008, por Alfredo Guarischi. Antes de destacar alguns pontos de interesse geral, não posso deixar de agradecer publicamente o próprio Guarischi pela parceria, bem como a presença de lideranças históricas do movimento de Medicina Hospitalar, como Rafaela Komorowski Dal Molin, do Hospital Mãe de Deus, de Porto Alegre; Breno Figueiredo Gomes, agora do Hospital Mater Dei, de Belo Horizonte; Alze Pereira dos Santos, do Paulistano; e até mesmo Clovis T. Bevilacqua Filho, já não diretamente envolvido com MH, mas co-responsável comigo e Valdir Ruzicki pelo primeiro site sobre hospitalistas do Brasil, de 2004.

O Congresso Brasileiro de Médicos Hospitalistas e o Safety2014 tiveram juntos cerca de 800 participantes (aguardo dados definitivos de Alfredo Guarischi), tendo a parceria sido provavelmente o principal fator responsável pelo expressivo números de médicos em evento primordialmente de segurança do paciente, batendo de longe números obtidos em outros Safetys.

Coube a Gibran Avelino Frandoloso, de Curitiba, na imagem abaixo, apresentar o hospitalista e o trabalho desenvolvido por nosso grupo. Lançou nossa próxima iniciativa, o I Encontro Paranaense de Médicos Hospitalistas, a ocorrer logo mais em outubro.


Dito isto, quero destacar dois palestrantes, um nacional e outro internacional, e algumas questões técnicas ou operacionais:

O engenheiro de produção carioca Felipe Espindola Treistman trouxe a seguinte provocação aos participantes: “Podemos aprender algo com os hospitais indianos?”. Tendo realizado uma missão técnica na Índia, apresentou informações e dados muito interessantes:

- O grupo Aravind realiza sozinho, em um ano, mais do que a metade de todas as cirurgias oftalmológicas realizadas no sistema inglês. À um custo muito, mas muito menor, do que no NHS.

- Nada disto seria importante se houvesse mais eventos adversos. No entanto, os resultados lá são melhores também neste quesito.

Quais foram algumas características observadas por Felipe dos hospitais indianos de referência visitados?

- Possuem processos altamente padronizados;

- Todos os profissionais (inclusive médicos) atuam em dedicação exclusiva;

- O trabalho do médico é focado nas tarefas mais complexas e que agregam valor, em paralelo ao aumento da participação de enfermeiros, técnicos e outros profissionais;

- Há flexibilidade de alocação dos médicos (em nome da eficiência, em um paralelo com um serviço de emergência brasileiro, não houvesse pacientes no setor de graves, o médico ali posicionado passaria a atender “consultinhas”, colaborando para o encurtamento da fila e otimização dos tempos);

- Distribuição inicial dos profissionais baseada em previsão confiável da demanda e, portanto, variável;

- Executam intensa análise de indicadores de produtividade e qualidade;

- Reuniões periódicas de análise de indicadores são feitas com presença de gestores, médicos e demais profissionais;

- Auditorias internas diárias para avaliar a qualidade de preenchimento dos prontuários.

O outro é o hospitalista John Bulger, fundador do Programa de Medicina Hospitalar do Geisinger Medical Center, Chief Quality Officer for the Geisinger Health System e membro da Agency for Healthcare Research and Quality e do National Quality Forum, EUA.

Apresentou o ProvenCare®, iniciativa de sua organização, altamente relevante, e provavelmente replicável em nosso meio.

Trata-se de um programa para entrega a todos os pacientes e a todo momento, em situações específicas, de cuidados baseados nas melhores evidências. O primeira testada por eles foi cirurgia cardíaca, onde reduziram expressivamente tempo de internação, readmissões, mortalidade e custos. Veja parte da apresentação abaixo:


ProvenCare® inclui módulos com os seguintes componentes:

- Definição clara do que constitui cuidado apropriado na situação especifíca;

- Desenvolvimento de consenso local sobre quais práticas devem SEMPRE ser entregues;

- Aprimoramento do fluxo de trabalho, incluindo melhorias de prontuário eletrônico para facilitar os profissionais na identificação e na tomada de decisão;

- Ativação de pacientes e familiares;

- Monitoramento e feedback das performances de grupos e indivíduos;

- Empacotamento como modelo de remuneração (opcional).

Tal como Felipe com a experiência indiana, Bulger destacou fortemente o papel da padronização para os resultados obtidos.

Já em sua outra palestra, o hospitalista, autor principal das recomendações da Society of Hospital Medicina para a Choosing Wisely®, destacou fontes de desperdício de recursos na Medicina Hospitalar e uma lista de coisas que NÃO devem ser feitas, em benefício do sistema e, principalmente, dos pacientes: veja no post anterior.

quinta-feira, 31 de julho de 2014

quarta-feira, 23 de julho de 2014

Confundem hospitalistas

Ainda há muito trabalho de promoção do conceito a ser feito.

Em hospital onde atuo como intensivista, recentemente fui convidado para palestrar na principal atividade científica. Assunto: Time de Resposta Rápida. Indiquei colegas com maior experiência. Houve certa insistência, eu havia sido bem recomendado, afinal de contas era ou não era expert em hospitalistas????

Trata-se de histórica confusão entre hospitalistas e TRR, já discutida em:



Depois outros disseram-me que poderia ter usado da experiência na implantação de TRR no HDP, que deveria ter aceitado igual. O fato é que o evento ficou melhor assim:


segunda-feira, 21 de julho de 2014

Algumas mensagens de hospitalistas norte-americanos para mim, ao longo destes anos…

Divulgação de textos ou depoimentos daqueles que iniciaram e promoveram a MH nos EUA é fundamental para melhor aproveitamento do modelo em nosso meio (parte 1)

de Robert Wachter, 2010

"It is gratifying to watch the growth of the hospitalist movement in Brazil. As you know, the field has grown remarkably quickly in the US, and it is now the fastest growing specialty in American medical history. Its growth has been driven by both research and experience documenting that strong hospitalist programs lead to improved quality, efficiency, and medical education. Moreover, with the increasing emphasis on improving systems of care, hospitalists came along at precisely the right time: their focus on both the care of individual patients and on making hospital systems work better is now considered the leading edge of an attitude we're trying to promote in all our physicians.

Early on, many hospitalists in the United States complained that they were not considered full-fledged physicians; some talked about being treated like "super-residents." Although I still hear this complaint from time to time, it is now fairly unusual. Most physicians, hospitals, and patients have recognized the central role of hospitalists in direct care and coordination, and hospitalists have assumed their role at the center of many systems. In fact, increasing numbers of hospitalists are assuming leadership positions. At the University of California, San Francisco (UCSF), for example, hospitalists in my group are now the Associate Chief Medical Officer, the Medical Director for Information Technology, and the Associate Chair for Safety and Quality (in addition to a number of other important roles). This is one small window into the fact that our hospitalists are now considered full-fledged, highly respected members of the medical staff.

This transition is natural; while there are things that hospitalists can and should do to move it along, it is the natural evolution of a specialty, as it transitions from new idea into a mature field with well trained specialists, separate certification, and widespread recognition of its value. Hospitalists bring such value to all of the parties: primary care doctors, specialists, hospital leaders, and most importantly, patients. It is just a matter of time before this value is fully recognized in Brazil.

-- Bob Wachter"
de Joseph A. Miller (Senior Vice President, Society of Hospital Medicine), 2008
"Hospital Medicine has grown as a marketplace phenomena, not because of any mandate. A few things drove this development here:

1st, community physicians were not willing to take call to cover the emergencies at their hospitals. Hospitals were forced to hire hospitalists to assume responsibility for "unassigned patients" in the emergency department. Community physicians did not complain about this because this was taking a burden off of them.

In parallel with this, managed care oversight impacted the amount of inpatient "business" for community physicians. With fewer and fewer patients in the hospital (and those that were in the hospital being complex, sick patients), the economics of doing inpatient care became less desirable for community physicians. In a slow but steady fashion, community physicians began to refer their patients to hospitalists.

In addition, 2 other "forces" impacted the growth of hospital medicine. 1) At teaching hospitals, resident work hours were limited by new national policy. Thus, hospitalists had to be hired to assume to front line responsibility for patient care at teaching hospitals. 2) Multi-specialty group practices made the decision to implement hospitals because they saw it as a superior model and one that made sense economically and from a lifestyle perspective.

Thus, although there was outright hostility to hospitalists in the early days, once a program is implemented at a given hospital, often the most vocal critics change their minds within relatively short periods of time.
Good luck!

JOE"

de Gregory Maynard, UCSD, 2008 (C’mon in, the water is just fine)

"I present to you a few thoughts on hospital medicine and the role that “hospitalists” play in the United States. Of course, your local environments are not identical to the USA environment, but I believe the basic dynamics and the potential for hospital medicine are the same. It is my perception that Brazil is now at a stage that was prevalent in the US about ten years ago, with respects to hospitalists and the role that they play. At that time, the concept of physicians dedicated to hospital medicine was fairly new, and many in the medical community viewed this development with alarm and suspicion. There were many myths and fears that were soon swept aside by the realities of the benefits of hospital medicine. I present some of the more common fears to you, along with a more current view of the reality in the US.

Myth:
Hospitalists will steal my patients.

Reality:
Hospitalists are dedicated inpatient clinicians. They do not have outpatient practices. They can assume primary care for patients while they are in the hospital, but depend on community physicians to provide post hospitalization care. Generally, use of hospital medicine services in voluntary.

Myth:
I will lose prestige and money if I use hospitalists to provide care for my hospitalized patients.

Reality:
The early reluctance to use hospitalists in the US has largely disappeared, as evidenced by the astronomical growth of the hospital medicine movement here. Much of the growth of hospital medicine in the US is fueled by the advantages they provide to community physicians, surgeons, and sub-specialists. These groups soon realized that they could work much more efficiently in their office or consultative settings when they did not have to go from the office to the hospital setting every day, take care of patients in the middle of the night, or go to several hospitals in a day. The reimbursement for their relatively small inpatient practice was not worth the travel time and time lost from their core work. Patients appreciated having a physician that was very familiar with the inner workings of the hospital available to them for more the day. Providing that their primary care provider and hospitalist communicate and explain their respective roles, patient satisfaction with the arrangement is very good.

Myth:
Hospitalists should restrict their work to urgent / emergent needs of inpatients when I am not physically present.

Reality:
Hospitalists are uniquely positioned to take comprehensive care of the inpatient with complex problems. Their availability is only one of the reasons why they produce better outcomes than non-hospitalists in study after study. They are vested in making the hospital environment and the systems of care better and safer for patients and staff. They ‘own’ rather than ‘rent’ the use of the hospital and the complex systems within it, and are rapidly assuming leadership roles in all manner of quality and safety initiatives. They are constantly focused on protocols and the standardization of care in their work environment, and the modern medical center needs this kind of focus to improve their overall patient outcomes.

I suggest you find a good hospitalist group and make sure you have a communication plan worked out, and just try the arrangement on a few of your patients… you’ll soon see the advantages for yourself. C’mon in, the water is just fine.

Regards.
Greg Maynard MD, MSc
Clinical Professor of Medicine and Chief, Division of Hospital Medicine
University of California, San Diego"

domingo, 20 de julho de 2014

Perversidades decorrentes de um modelo de remuneração maluco


Hospitalistas brasileiros inovando. Para ver muitos pacientes (quantos assim precisariam permanecer internados?), criaram um carimbo que facilita o registro diário...
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