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Resumen Desde la Antiguedad los medicos han necesitado, y solicitado, el apoyo y consejo de colegas experimentados. Esta practica fue refrendada por Hipocrates y Galeno, permaneciendo sin cambios hasta la Ilustracion. En ese periodo, la interconsulta alcanzo un gran auge. Se escribieron libros monograficos, se estudiaron las caracteristicas y cualidades que debia poseer el medico consultor y los problemas que podia originar, y se establecieron reglas y pautas a seguir durante su desarrollo. Esta situacion se mantuvo estable hasta finales del siglo xix , cuando la aparicion de diversas especialidades medicas ofrecio la posibilidad de buscar ayuda especializada. Esta especializacion origino una fragmentacion de la asistencia medica, lo que favorecio la aparicion del internista como «consultor universal». En el ultimo cuarto del siglo xx , ante la importancia y problemas de la interconsulta, se comienza a desarrollar su estudio, se crean servicios especializados en su resolucion y, finalmente, aparece la asistencia compartida.

Introduction. Several factors have been associated with the prognosis of prosthetic joint infection (PJI) treated with surgical debridement, antibiotic therapy, and implant retention (DAIR). There is no evidence about the right empirical antibiotic treatment when the causal microorganism is not still identified. Material and methods. We conducted a retrospective observational study in patients with PJI treated with DAIR between 2009 and 2018 in our center. We analyze the risk factors related with their prognosis and the influence of active empirical antibiotic therapy against causative microorganisms in final outcomes. Results. A total of 80 PJI cases treated with DAIR, from 79 patients (58.7% women, mean age 76.3 years), were included in the study period. Among the cases in which empirical antibiotic therapy were active against the causative microorganisms, the success rate was 46/65 (69.2%) vs 1/15 when not (6.7%, OR 31.5, p = 0.001). Factors related to the success or failure of the DAIR were analyzed with multivariate analysis. We found that active empirical antibiotic treatment remained statistically significant as a good prognostic factor (OR 0.04, p

Resumen La mayoria de los pacientes quirurgicos hospitalizados tiene mucha comorbilidad medica y recibe un gran numero de medicaciones, o sufre complicaciones importantes, o ambos. La asistencia compartida (AC) es la responsabilidad y autoridad compartidas en el manejo de un paciente hospitalizado. Se discute si se deben seleccionar o no pacientes para la AC. Los diferentes criterios de seleccion no son seguros o faciles de aplicar, y dejan fuera a muchos pacientes subsidiarios de AC. El manejo perioperatorio es fundamental para la mortalidad postoperatoria. El fallo del rescate (mortalidad hospitalaria secundaria a complicaciones posquirurgicas) es el principal factor sobre la mortalidad quirurgica hospitalaria. Afecta a cualquier paciente, independientemente de su edad, comorbilidad o tipo de cirugia. El componente que reduce mas el fallo de rescate es la presencia de internistas en las salas quirurgicas. Consideramos que todos los enfermos hospitalizados en los servicios quirurgicos deberian recibir AC.

Most hospitalized surgical patients have significant medical comorbidity and are treated with a considerable number of drugs and/or experience significant complications. Shared care (SC) is the shared responsibility and authority in managing hospitalized patients. In this article, we discuss whether patients should be selected for SC or not. The various selection criteria are not an exact science nor are they easy to apply. Furthermore, they may leave out many patients who may be good candidates for SC. Perioperative management is essential for preventing postoperative mortality. Failure to rescue (in-hospital mortality secondary to postoperative complications) is the main factor linked to in-hospital surgical mortality and can affect any patient regardless of age, comorbidity, or type of surgery. The component that most reduces failure to rescue is the presence of internists in surgical wards. We believe that all patients hospitalized in surgery departments should receive SC.

Resumen Antecedentes y objetivo Los enfermos quirurgicos hospitalizados estan aumentando su complejidad medica, incrementando la necesidad de apoyo por Medicina Interna. Este apoyo se realiza mediante la interconsulta, la cual presenta problemas que han inducido el desarrollo de la asistencia compartida (AC). Nuestro objetivo es comparar los resultados asistenciales alcanzados por los modelos de interconsulta y AC en Cirugia Ortopedica y Traumatologia. Material y metodo Estudio observacional, prospectivo, multicentrico, de los enfermos hospitalizados de urgencia en Cirugia Ortopedica y Traumatologia recogidos en el registro REINA-SEMI, atendidos por Medicina Interna mediante interconsulta o AC. Se registraron las caracteristicas demograficas, comorbilidad, complicaciones medicas, estancia hospitalaria y mortalidad. Resultados Se incluyeron 697 pacientes, 415 con AC y 282 con interconsulta. Los de AC tenian mas edad (78,9 vs. 74,3; p Conclusiones La AC ofrece mejores resultados asistenciales que las interconsultas en pacientes ingresados de urgencia en Cirugia Ortopedica y Traumatologia.

Background and objectives Hospitalized surgical patients are increasing in medical complexity, thereby increasing the need for support by internal medicine departments. This support is provided through interconsultations, which present problems that have resulted in the development of shared care (SC). Our objective was to compare the healthcare results achieved by the SC and interconsultation models in orthopaedic surgery and trauma (OTS). Materials and Methods We conducted an observational, prospective, multicentre study of patients hospitalized for emergency OTS recorded in the REINA-SEMI registry, treated by internal medicine departments through interconsultation or SC. We recorded the demographic characteristics, comorbidity, medical complications, hospital stay and mortality. Results The study included 697 patients, 415 with SC and 282 with interconsultations. The SC patients were older (78.9 vs. 74.3; p Conclusions SC offers better healthcare results than interconsultations for patients hospitalized for emergency OTS.

Resumen Objetivo Analizar la actividad de interconsulta (IC) realizada por los servicios de medicina interna (MI), sus aspectos formales, el perfil de la atencion clinica requerida y cuantificar la carga de trabajo que supone. Material y metodo Estudio multicentrico, observacional, prospectivo, sobre enfermos consecutivos hospitalizados atendidos por servicios de MI mediante IC entre el 15 de mayo y el 15 de junio del ano 2016. Se estimo la carga de trabajo relacionada con dicha actividad (1 UT = 10 min). Resultados Se registraron 1.141 IC procedentes de 43 hospitales, edad 69,4 (DE: 16,2) anos, 51,2% hombres. El indice de Charlson fue 2,3 (DE: 2,2). Los motivos de consulta mas frecuentes fueron: valoracion general (27,4%), fiebre (18,1%), disnea (13,6%), trastorno metabolico (9,6%), HTA (6,3%) y sindrome confusional (5,3%). Las UT estimadas fueron 4 (DE: 5,9) para la primera visita y 7,3 (DE: 21,5) para la suma de las sucesivas. Los pacientes quirurgicos fueron mayores (70,6 [DE: 15,9] vs 64,4 [DE: 16,3]; p = 0,0001) y precisaron mas dias de seguimiento (5 [DE: 7,3] vs 3,5 [DE: 4,2]; p = 0,009). Los siguientes aspectos fueron mas frecuentes en el formato de las IC realizadas por servicios medicos: numero de IC ordinarias (respuesta > 24 h), especificacion del motivo de IC, datos minimos referentes a la historia clinica y coincidencia de la adecuacion en el tiempo con el consultor. Conclusion Los pacientes atendidos mediante IC por los servicios de MI representan una carga de trabajo importante. La adecuacion al formato de solicitud de IC es mayor en las procedentes de servicios medicos.

Objective To analyze the activity of interconsultations conducted by internal medicine (IM) departments, their formal aspects and the profile of clinical care required and to quantify the workload they represent. Material and method A multicentre, observational prospective study was conducted with consecutive hospitalized patients treated by IM departments using interconsultations between May 15 and June 15, 2016. We estimated the workload related to this activity (1 time unit [TU] = 10 min). Results We recorded 1141 interconsultations from 43 hospitals. The mean age of the patients involved was 69.4 years (SD: 16.2), and 51.2% were men. The mean Charlson index was 2.3 (SD: 2.2). The most common reasons for the consultations were general assessments (27.4%), fever (18.1%), dyspnea (13.6%), metabolic disorder (9.6%), arterial hypertension (6.3%) and delirium (5.3%). The duration of the first visit was 4 TUs (SD: 5.9) and 7.3 (SD: 21.5) for the sum of all subsequent visits. The surgical patients were older (70.6 [SD, 15.9] vs. 64.4 [SD, 16.3] years; p = .0001) and required more follow-up time (5 [SD, 7.3] vs. 3.5 [SD, 4.2] days; p = .009). The following issues were more common in the interconsultation format performed by medical services: number of regular interconsultations (response >24 h), specification of the reason for the interconsultation, minimal data regarding the medical history and agreement on the appropriateness of the time spent with the consultant. Conclusion The patients treated through interconsultations by the IM departments represented a significant workload. The interconsultations from the medical departments were more in line with the request format.

Objectives To analyse the activity of interconsultations conducted by the departments of internal medicine, communicating their importance to managers and offering information to these departments to improve their organisation. Methods A cross-sectional study was conducted using an interconsultation activity survey (on-demand consulting activity for other departments) and shared care (consulting activity provided in a regulated manner to other departments). Results We received 120 surveys that corresponded to 108 public and 12 private hospitals. Forty-five percent of the surveyed hospitals had a specialised interconsultation unit, and 31% had shared care. The department most frequently helped by the presence of a stable consultation unit (65% of the cases) was orthopaedic and trauma surgery. Fifty-five percent of the departments of internal medicine surveyed had an interconsultation activity record since the start of their activity. Ninety-two percent of the departments lacked a protocol that regulated interconsultations, and in 74% of the cases, the interconsultation was on demand. Conclusions The interconsultation activity is generalised in the departments of internal medicine, but only 45% of these departments have interconsultation units, and only 33% provide the shared care modality. The survey reflects the shortcomings of training and some confusion in the concept of interconsultations. The considerable majority of departments lack organisational interconsultation protocols.

Resumen Objetivos Analizar la actividad de interconsulta (IC), realizada por los Servicios de Medicina Interna (SMI), transmitir su importancia a los gestores y ofrecer informacion a los SMI para mejorar la organizacion de la misma. Metodos Estudio transversal mediante una encuesta de actividad en IC (actividad de consultoria a demanda para otros servicios) y asistencia compartida (actividad de consultoria que se presta de modo reglado en otros servicios). Resultados Se recibieron 120 encuestas que correspondian a 108 hospitales publicos y 12 privados. El 45% de los hospitales encuestados disponen de unidad de IC monografica y en el 31% existe asistencia compartida. El servicio mas frecuentemente asistido por una consultoria estable (65% de los casos) fue cirugia ortopedica y traumatologia. El 55% de los SMI encuestados lleva un registro de la actividad de IC desde el inicio de su actividad. El 92% de los servicios carece de un protocolo que regule la IC y en el 74% de los casos la IC se responde a demanda. Conclusiones La actividad de IC esta generalizada en los SMI, pero solo el 45% de ellos disponen de unidades de IC y el 33% prestan la modalidad de asistencia compartida. La encuesta refleja carencias de formacion y cierta confusion en el concepto de IC. La gran mayoria de los servicios carecen de protocolos organizativos de IC.

Surgical departments have increasing difficulties in caring for their hospitalised patients due to the patients’ advanced age and comorbidity, the growing specialization in medical training and the strong political-healthcare pressure that a healthcare organization places on them, where surgical acts take precedence over other activities. The pressure exerted by these departments on the medical area and the deficient response by the interconsultation system have led to the development of a different healthcare organization model: Shared care, which includes perioperative medicine. In this model, 2 different specialists share the responsibility and authority in caring for hospitalised surgical patients. Internal medicine is the most appropriate specialty for shared care. Internists who exercise this responsibility should have certain characteristics and must overcome a number of concerns from the surgeon and anesthesiologist.

Medical interconsultation for hospitalised patients is a regular activity among internal medicine specialists. However, despite its growing impact and importance, a model that defines its characteristics, objectives and information has not been established. This study, conducted by the Shared Care and Interconsultations Group of the Spanish Society of Internal Medicine, proposes a number of general recommendations concerning the method for requesting and responding to hospital medical interconsultations, as well as a format for these interconsultations.

Resumen La interconsulta medica en pacientes hospitalizados constituye una actividad habitual entre los especialistas en medicina interna. Sin embargo, a pesar de su impacto e importancia crecientes, no se ha establecido un modelo que defina sus caracteristicas, sus objetivos o la informacion que debe contener. En este trabajo, desde el Grupo de Asistencia Compartida e Interconsultas de la Sociedad Espanola de Medicina Interna, se proponen unas recomendaciones generales respecto a la forma de solicitar y de responder una interconsulta medica hospitalaria, asi como un formato para la misma.

Surgical departments have increasing difficulties in caring for their hospitalised patients due to the patients’ advanced age and comorbidity, the growing specialisation in medical training and the strong political-healthcare pressure that a healthcare organisation places on them, where surgical acts take precedence over other activities. The pressure exerted by these departments on the medical area and the deficient response by the interconsultation system have led to the development of a different healthcare organisation model: Shared care, which includes perioperative medicine. In this model, 2 different specialists share the responsibility and authority in caring for hospitalised surgical patients. Internal Medicine is the most appropriate specialty for shared care. Internists who exercise this responsibility should have certain characteristics and must overcome a number of concerns from the surgeon and anaesthesiologist.

Objective Patients admitted to the Department of Ophthalmology (OPH) are of increasing age, comorbidity and complexity, leading to increased consultations/referrals to Internal Medicine (IM). An alternative to consultations/referrals is co-management. The effect of co-management on length of hospital stay was studied in patients admitted to OPH. Methods Retrospective observational study was performed that included patients ≥14 years old discharged from OPH between 1 January 2009 and 30 June 2013, who were co-managed from May 2011. An analysis was made including age, sex, type of admission, whether it was operated on, administrative weight associated with GRD, total number of discharge diagnoses, Charlson comorbidity index (CCI), mortality, readmissions, and LoS. Results There were statistically significant differences between the groups in operated patients (odds ratio [OR] 2.3, 95% confidence interval [95% CI] 1.5 to 3.6), administrative weight (0.1160; 95% CI 0.0738 to 0.1583), and number of diagnoses (0.9, 95% CI 0.5 to 1.3). On adjustment, co-management reduced LoS in OPH by 27.8%, 0.5 days (95% CI 0.1 to 1). Conclusions Patients admitted to OPH have increasing comorbidity and complexity. Co-management is associated with a reduced LoS and costs in OPH, similar to that observed in other surgical services.

Resumen El perfil del paciente hospitalizado se esta modificando hacia enfermos pluripatologicos, ancianos y con elevada comorbilidad. La complejidad creciente de su asistencia, la progresiva superespecializacion medica y los problemas organizativos que dificultan con frecuencia el seguimiento diario del paciente por el mismo facultativo, han favorecido un aumento progresivo de la participacion de los servicios medicos, en especial Medicina Interna, en la atencion a los pacientes ingresados en otras especialidades medicas y quirurgicas. La actividad hospitalaria que los servicios de Medicina Interna desempenan fuera de los mismos no dispone de definiciones y criterios bien establecidos a nivel organizativo, su valoracion y contabilidad es diferente en cada hospital. En este documento establecemos las definiciones de asistencia compartida, medicina consultiva, medicina perioperatoria y de interconsulta, asi como sus tipos en cuanto a prioridad, formalidad, ambito de atencion, adecuacion en el tiempo, relacion con la cirugia y otras circunstancias.

Objective An important but understudied activity of the departments of internal medicine (IM) is the in-hospital consultations. We analyzed the requests for in-hospital consultation with IM and the potential differences between the consultations of medical and surgical departments. Patients and methods This was an 8-month observational prospective study that analyzed demographic variables related to the origin of the interconsultation, comorbidity, length of stay and hospital mortality, emergency, admission-consultation request delay, appropriateness (not appropriate if another department was consulted for the same reason or if the pathology behind the consultation was that of the requesting service) and, for patients who underwent surgery, whether it was requested before or after the surgery. Results During the study, 215 in-hospital consultations were conducted (27 consultations/month). The mean age of the patients was 69.8 years (women, 50%). Some 30.7% were requested by medical departments and 69.3% by surgical departments. Thirteen percent of the in-hospital consultations were duplicated. The department of IM was not the appropriate department consulted in 23.3% of cases (13.0% of the cases requested consultations for the same reason with another department; in 14.3% of the cases, the pathology was that of requesting department). More in-hospital consultations were conducted on Mondays and Fridays than on Thursdays (25.1% and 23.7% versus 15.3%, respectively; p = .03). The delay between admission and the request for interconsultation was of 12.6 days. Some 90.7% of the in-hospital consultations for patients undergoing surgery were requested after the intervention. There were no differences in the characteristics of the in-hospital consultations between the medical and surgical departments. Conclusions In-hospital consultations directed at IM are frequently duplicate, are not well directed at the appropriate department and their urgency is incorrectly assessed. These characteristics are similar for the consultations with medical and surgical departments.

Resumen Objetivo Una actividad importante y poco estudiada de los servicios de medicina interna (MI) son las interconsultas. Hemos analizado las solicitudes de interconsulta a MI y posibles diferencias entre las consultas de los servicios medicos y quirurgicos. Pacientes y metodos Estudio observacional prospectivo de 8 meses de duracion. Se analizaron variables demograficas, relacionadas con la procedencia de la interconsulta, comorbilidad, estancia y mortalidad hospitalaria, urgencia, demora ingreso-solicitud, adecuacion (no adecuado si otro servicio habia sido consultado por el mismo motivo o porque la enfermedad motivo de consulta era propia del servicio solicitante) y, en los pacientes intervenidos quirurgicamente, si fue solicitada antes o despues de la intervencion. Resultados En el tiempo de estudio se recibieron 215 interconsultas (27 consultas/mes). La edad media fue de 69,8 anos (mujeres 50%). El 30,7% fueron solicitadas por servicios medicos y el 69,3% por servicios quirurgicos. Un 13% de las interconsultas estuvieron duplicadas. El servicio de MI no era el servicio consultado adecuado en el 23,3% (13,0% solicitadas por el mismo motivo a otro servicio y en el 14,3% la enfermedad era propia del servicio solicitante). Los lunes y viernes se formularon mas interconsultas que los jueves (25,1 y 23,7% versus 15,3%; respectivamente, p = 0,03). La demora entre el ingreso y la solicitud de interconsulta fue de 12,6 dias. El 90,7% de las interconsultas solicitadas a pacientes intervenidos se emitieron despues de la intervencion. No hubo diferencias en las caracteristicas de las interconsultas entre los servicios medicos y quirurgicos. Conclusiones Las interconsultas dirigidas a MI con frecuencia son duplicadas, no estan bien dirigidas al servicio adecuado y se aprecia una incorrecta valoracion de su urgencia. Estas caracteristicas son similares para las consultas de los servicios medicos y quirurgicos.

The physician on-call is a fundamental support for modern in-patient care. The majority of the time during which a patient is in the hospital, he/she is under their care. There is almost no information about its clinical aspects. These are greatly influenced by the patient, his/her family, other patients and their relatives, catering services, some special situations, nursing personnel, and the doctor both as the main responsible person for the patient and as the physician on-call. As the doctor on call, he/she should have a clear idea of what the objectives are, achieve good management of the calls received, make the difference corresponding decisions and help the work of the patient's responsible physician. It is necessary to analyze and adapt the amount of work that the physician on-call has.

Pleural effusion (PE) can change the equilibrium between volume of thoracic cavity and volume of intrathoracic structures, and it can disturb the function of respiratory system, heart, and diaphragm. PE alters scanty the pulmonary gas exchange, but it provokes restrictive changes in pulmonary function proportionally to fluid volume, increase thoracic diameters, and decrease lung compliance. PE can originate a syndrome similar to cardiac tamponade. Elevate intrapleural pressure increase intrapericardic pressure and this disturb the cardiac chambers filling, specially right chambers, and decrease cardiac output. Large PE can invert the diaphragm inducing paradoxical movement that origin a reduction of alveolar ventilation. All these alterations improve with drainage of the PE. We think that PE must always be drained, specially if respiratory failure is present.