Current and future structure and organization in the assistance of renal patients in chronic haemodialysis Piergiorgio Bolasco
Definitions according to regional regulations (resolution 25/29 dated 1st July 2010) The Dialysis Reference Centre is an intensive support centre, belonging to an Operational Nephrology Unit equipped with in-patient beds. The centre is in charge of providing assistance to clinically unstable and high-comorbidity patients and emergency patients. The Territorial Assistance Dialysis Centre (CAD) is a specialized structure the aim of which is to guarantee dialysis treatment to clinically unstable patients thanks to the continuous presence of a nephrologist throughout the dialysis session. This type of assistance is reserved to patients devoid of intensive or sub-intensive critical characteristics. The Territorial Careful Assistance Dialysis Centre (CAL) is a specialized structure aimed at guaranteeing dialysis treatment to patients judged as being clinically stable by nephrologist. The opening and support of this type of centre is characterized by the offer of an easily accessible localized service not requiring the presence of a nephrologist during treatment, and lower costs.
Current situation in the Province of Cagliari � one Reference Centre for Nephrology Dialysis and Transplant in a Hospital with high hospitalization rates - G. Brotzu Hospital � one Reference Centre for Dialysis Emergencies and Assistance to patients in chronic dialysis, also providing specialist care for contagious patients (HBV+ and HIV+) � ASL Cagliari � one Territorial Structure made up of 5 centres for dialysis: one coordination CAD, one hospital CAD, one hospital CAL, 2 community CALs � ASL Cagliari
Local distribution of Public Centres for Local distribution of Public Centres for Nephrology and Dialysis Nephrology and Dialysis Province of Cagliari Province of Cagliari
Obstacles to the application of virtuous organization models � The only centre with in-patient beds (the increasing demand results in an overload of the structure for patients referring to the centre) is the Brotzu Hospital (managed by a different authority to the ASL in Cagliari). � Critical lack of renal beds in the ASL of Cagliari capable of � lightening the load � of the Brotzu Hospital Reference Centre. � In the area covered by the ASL of Cagliari renal patients are only � accepted � in two suburban hospitals, usually on General Medical Wards. � The territory is affected by numerous geographical issues and poor road access. The two suburban centres are located 60 and 75 Km from Cagliari. � There is no political-administrative impetus to formalize the relationships and procedures between the two HS centres. � High incidence of new dialysis patients controlled by the three private dialysis centers that already provide assistance to over 200 patients.
The figures in the public structures The figures in the public structures The figures in the public structures � Brotzu Hospital: 110 haemodialysis patients, 47 receiving peritoneal dialysis, 6 hemodialysis emergency beds, 26 beds for residential renal and 10 transplant patients, 2 D.H. places, >750 transplant patients followed up periodically + biopsies & vascular access activities, 13 operational outpatients � clinics. � ASL Cagliari: total 240 haemodialysis patients in 6 centres, 0 beds for residential renal patients, vascular access activity,14 operational outpatients � clinics in the territory (Cagliari & surroundings).
The � modus operandi � we adhere to in the lack of formal regulations: a � brotherhood � policy Monastir Monastir Muravera Muravera spokes spokes Hub: Hub: Quartu Quartu Sarroch Sarroch - Brotzu Brotzu � Sant � - Elena Sant Elena - SS. Trinit SS. Trinità à - Others in Others in Isili Isili progress progress
To what extent do sick people still feel protected in hospital? � � In Hospital the individual Life in the outside feels better taken care of than environment is better � anywhere else Hospital infections are a � He expects his/her illness to serious problem � be cured Patients no longer enjoy their stays in hospital � Alternative medical care facilities have developing
Hospital Territory integration
Integration � Programmatic integration : a fundamental aspect for the definition of strategic choices and priorities, in relation to the awareness of territorial requirements, from the services provided to the resources available within each health area; � Institutional integration: which requires the establishing of collaborations between different institutions (ASL, local authorities etc.) arranged with a view to achieving mutual objectives for global health, extended also to the life of a person in his/her community; � Managerial integration: in the organizational and operative choices between the different operative structures: unitary within health area throughout the different services comprised; � Professional integration: strictly linked to the adoption of company profiles and guidelines aimed at steering inter-professional work towards the production of home, semi-residential and residential health services
Integration: focus on the sector H requests that the territory solve the problems it cannot control unaided The territory � dumps � the problems it cannot control on the hospital T Integration: global focus The solution is to avoid conflicts of The solution is to avoid conflicts of authority and provide a reciprocal authority and provide a reciprocal guarantee of maximum availability in guarantee of maximum availability in accepting patients for treatment accepting patients for treatment The assistance programme is whenever staff and resources allow whenever staff and resources allow organized and managed in a synergistic manner
Together but how? � By defining scheduled methodological procedures and assistance to be applied in both a routine and emergency situation. � By requesting that Institutions unify the functional government in order to create an � integrated functional network � � By attempting to unify the organization of services � By implementing comparable technological acquisitions common to both the Hospitals and the territory based on clinical involvement and patients � needs � By developing integrated economic programmes: unity determines a positive impact on the acquisition of goods
Types of instruments for integration � Functional programmes conceived for specific pathologies with admission of patients with particular problems to HUB hospitals; � Functional programmes according to the type of patient: stable or not heavy unstable: allocation of the patient to the territory nearest their place of residence; � The � critical � patient should temporarily or momentarily stay in the HUB hospital; � The territory should be provided with patient transportation facilities for use under routine and emergency conditions; � ideal target: integrated hospital-territory departments?
The results we would expect � More effective assistance; � Rationalization of organization; � Focus the attention of the Health Services on the PATIENT; � Cost-effectiveness and rationalization of expenditure;
Elements to be implemented -a � Guarantee application of the Essential Assistance Limits (LEA) for all citizens, irrespective of their health care facility; � Improvement through homogeneous procedures of hospital and territorial outpatients � clinics with a strong focus on prevention aimed at slowing down the � race � to dialysis. � Creation of highly specialized nephrology clinics: e.g. nutrition, doppler ultrasonography, study of vascular access, treatment of CKD-MBD etc.
Elements to be implemented- b � Establish a productive and collaborative dialogue with General Phisicians (including their active participation in the definition of Hospital-territory assistance programmes); � Avoid self-referencing: promoting exchanges of teams capable of undertaking control audits, either internal or managed by external agencies. � Protected shared tele-network accessible to both parties (e.g. access to updated medical charts in Hospital and on the Territory)
Cultural delay of the territory Cultural delay of the territory Cultural delay of the territory H � T integration is linked to: medical: medical: focused on socio- -sanitary sanitary focused on socio programmes for chronic programmes for chronic New culture conditions conditions throughout the territory organizational/managerial focused organizational/managerial on activities developed in healthcare centres, to be integrated IN THE LACK OF A NEW CULTURE FOR THE TERRITORY ⇓ TERRITORIAL HOSPITALIZATION WILL PREVAIL
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