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This working proposal aims to establish an Internal Medicine Network (IMN) model for the appropriate management of the poly-pathological complex patient in the different phases of his illness natural hystory. The IMN is based on an organization recalling the Hub and Spoke system already used for existing specialized networks. The Internal Medicine Unit (IMU) is the natural destination of acutely ill patients suffering from systemic or multi-organ diseases. Three are the IMU specific tasks: i) to stabilize acute, severe, poly-pathologic and complex patients; ii) to develop difficult etiological diagnosis in these patients and in those who should necessarily be admitted to the hospital, not being possible, for different reasons, alternative routes; iii) to select the acute poly-pathological complex patient's priorities. The expected results of a new model of integration system inside the IMN are: i) reduction and rationalization of expenditure in the medical area, increasing effectiveness, quality and safety guaranteeing patient centrality; ii) patients stratification based on characteristics of gravity, acute illness, estimated duration of hospitalization; iii) reduction of inappropriate hospital admissions ensuring connections between hospital and primary care units; iv) definition of different care pathways for patients hospitalized due to non-communicable diseases; v) implementation of new common medical records. The public-private partnership inside the IMN could be able to increase appropriateness reducing health costs. Patient-centered problems assessment, together with integration, cooperation, coordination and effective communication are some simple rules useful to achieve tangible results in a complex system and the IMN model represents its practical application. [ABSTRACT FROM AUTHOR]

The hospital internal medicine (IM) needs to adapt to the socio-demographic changes occurred during the last thirty years: patients currently show an increased overall complexity owing to the increase in the average age of the patients admitted, to more several and severe comorbidities, and a higher concentration in our wards of most severe cases. Our departments have to change in order to pursue a more efficient organization and to offer care to users modulated according to their needs and conditions. The Intensity of Care in Internal Medicine Group of the Federation of Associations of Hospital Doctors on Internal Medicine - Lazio carried out a population-based study in eight Internal Medicine wards of the region with the aim of characterizing the patients there admitted, using the modified early warning score (mEWS), monitoring and evaluating the outcomes of hospitalization. This has allowed us to determine the cut-off of the score indicating a greater statistical probability of a fatal outcome corresponding to 3, contrary to what originally reported by Subbe et al. in 2001. According to our results into the Departments of IM should be provided an area of high care, where monitor and stabilize the patients admitted with a mEWS score ≥ 3, before transferring them to the wards of lower intensity of care. This organizational model of the high care of medical patients has the benefit of offer the technical and professional assistance appropriate to the level of clinical risk, with more intensive care to more critical stages of illness. [ABSTRACT FROM AUTHOR]

The aim of the paper is to identify the role of the hospital Internal Medicine specialist in the Internal Medicine Unit (IMU) through a clinical and statistical analysis of the patients referred to them by identifying the activities that differentiate them from patients in General Medicine and Emergency Departments, i.e. diagnosis and treatment of complex patient with varying degrees of instability, identifying priorities in the acute problems of co-morbidities. The modified early warning score (MEWS), an internationally validated marker, was chosen to assess and stratify the clinical instability of patients referred to the IMU. A literature review was carried out, and a cut-off score of 3 was chosen to define the critical patients referred to the IMU; a MEWS value of 4 defines the need for transfer to the Intensive Care Unit (ICU) or Intensive Cardiac Care Unit (CCU), considered the primary end point in most of the studies examined. To better characterize the internist’s role today, a strength, weaknesses, opportunity, threats (SWOT) analysis was performed and examined, and commented upon. A total of 101 articles were reviewed and 5 were selected. The case histories relating to the IMU appear to be made up of complex patients with conditions that are, in most cases, acute and unstable. From 10% to 17% of patients present a MEWS of 3 or more that defines a condition of severe clinical instability requiring continuous observation and non-invasive multi-parametric monitoring. From 5% to 7% of cases present a MEWS of 4 or more and therefore require transfer to the ICU/CCU or risk rapid death. Approximately 40% of patients present MEWS of 1-2 and still have disease flare-up, but with a lesser degree of instability; however, these patients could experience a potentially negative disease development if not promptly and properly treated. Approximately 40% of patients have MEWS of 0 and represent the group of fragile patients that cannot be studied, diagnosed or stabilized on an outpatient basis. The critical analysis of the literature review and the SWOT analysis suggest that the two specific hospital internist’s tasks are: i) to stabilize acute, severe and complex patients with multiple pathologies; and ii) to develop etiologically difficult diagnoses in these and in fragile patients who need to be admitted to the hospital because the alternative diagnostic routes, for various reasons, cannot be used. [ABSTRACT FROM AUTHOR]