by Claudio Maria Maffei
07 MAY –
Dear director,
in my search for data and materials on the issue of hospitals and beds (of which almost everyone complains about the cuts and of which I point out the frequent redundancy and dispersion), I came across a very interesting document entitled “Organisational and management development of area
criticism and diagnostic therapeutic assistance path (PDTA) in the NHS” of the Superior Council of Health (CSS). The incipit of the Executive Summary clarifies the purpose of the document very well. He does it so well that I am reporting it almost in its entirety
“The DECREE-LAW of 19 May 2020, n. 34, introduced a “structural” increase in intensive care beds of at least 3500 beds such as to reach an endowment of 14 beds per 100,000 inhabitants when fully operational. Added to these are 4225 semi-intensive care beds resulting from the redevelopment of beds in the medical area, 50% of which can be transformed into intensive care stations. Once the emergency situation linked to the Covid-19 pandemic has been overcome, the implementation of this program to increase the number of intensive care and semi-intensive care beds in the various Regional Health Services has posed problems of appropriateness and sustainability.
In order to contribute to the resolution of these problems, Section I of the CSS deemed it appropriate to develop a proposal for an organizational meta-model for the management of the Critical Area (AC) whose main purposes are:
- provide the elements to evaluate the appropriateness of the investment necessary to implement the increase in intensive care and sub-intensive care beds;
- define an organizational meta-model to be progressively adopted by the Regions and autonomous Provinces which allows the sustainability of the increase in intensive care and sub-intensive care beds;
- provide guidelines to the Regions and autonomous Provinces to identify the infrastructural, technological and professional requirements necessary to respond to care needs in critical areas.”
The document is from February 2023 and therefore arrived late for the regional building intervention programs on the additional intensive and sub-intensive care beds envisaged by Legislative Decree 34, programs which had already chosen their location, but still in time to guide the organizational models for their management. Here I am not so much interested in going into the details of the analyzes and proposals of the document, of which I will limit myself to underlining the usefulness and some limitations, as in underlining the anomaly of how such a high profile document has a semi-clandestine circulation, probably similar to that of the other CSS publications.
The main merit of the Document is that it provides some very useful ideas in the (re)design of the intensive care networks in Italy, focusing on the model of the area defined as “system organized to provide the necessary care to patients in various critical conditions, through medical and nursing with the ability to modulate the monitoring and the multiple ways of supporting organ failure”. The document then provides indications on how to translate this model into corporate realities which for example envisages the confluence in this area of the cardiac intensive care units (ICU) and the stroke units with cardiological and neurological management. Another advantage is that of dedicating specific attention to critical areas in the pediatric field, an area in which there are strong shortages in Italy.
However, the main limitation of the document is, in my opinion, that it makes no connection with Ministerial Decree 70 and therefore does not formulate any proposal on the type of hospitals in which to place these areas and therefore on the number of structures that must be equipped with them in relation to the population and the type and volume of activity. Fundamental indications if we want, and this is certainly the intention of the CSS, that the reorganization of the critical areas of the hospitals is also compatible with the resources available. Perhaps someone else should have done this intertwining activity between the “new” critical area model and the planning and organizational standards of hospitals, for example that now legendary ministerial working group on DM 70 and DM 77.
Meanwhile, what’s happening in the real world? As always, I rely as an example on the reality of the Marche region that I know well:
- Health plans are moving forward which provide for many more hospitals with intensive care than those compatible with Ministerial Decree 70 (in the Marche region there are 14 existing or planned against the 10 from Ministerial Decree 70) with many intensive therapies of sub-optimal dimensions (at least 8 beds);
- new DEA building projects are being approved that do not take into account the critical area model of the CSS and the “reserve” beds needed in the event of a pandemic resurgence are being forgotten;
- there has not been even the slightest start of the training courses necessary for the creation of a critical area according to the CSS.
In short, perhaps not even the Ministry has read the Document (or if it has, it has only skimmed through it and in any case has not taken it into account) and most of the Regions have certainly not read it, such as the Marche region which has beds under intensive procedures for post-operative management were also provided for in a hospital in a disadvantaged area. I looked for the list of CSS publications and found it full of interesting ideas, as in the case of the one with the guidelines on robotic surgery (there are also those on Artificial Intelligence), a topic on which, again in the Marche, it is above all the Councilor who expresses himself, who establishes where to place it in the absence of any regional technical support document.
If all the CSS Documents go the way of this really good one in critical areas, we cannot be surprised that their production has become so sparse (one in the last year). A shame and a waste, I think.
Claudio Maria MaffeiCoordinator of the Pd Marche Health Table
07 May 2024
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