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On May 11, 2018, Aik commented on Should We Create a Cardiovascular IPU? :

I see a lot of positive developments and opportunities to create a cardiovascular IPU and it will be a nice adventure.
However, I also see one more additional challenge. In the Netherlands, our cardiologists and cardiothoracic surgeons focus predominantly on the heart and comorbidity is often not weighed in the (very) protocolized treatment schemes. E.g. for a very minor nonSTEMI with borderline troponine elevation full dose aspirin/clopidrogrel/nadroparin is given to a DM1 patient that just had a cerebral bleed (CVA) four days ago. What kills first? How is feedback established for (readmission for) a gastrointestinal bleed after warfarin initation, etc. In the Netherlands the complications of cardiovascular treatment (e.g. readmissions) are often not admitted to the cardiovascular IPU but to other deparments (acute care department or general medicine). Not sure if this is the case in the USA, but how to maintain a holistic view and proper feedback channels on outcome (complications) to weigh treatment against comorbity in an increasingly older and complex multi-morbid population.

On May 11, 2018, Aik commented on Optimized Care through Easy-to-Consult Protocols :

We use a software suite called iProva from Infoland ( to document all protocols with google like search function for your specialty, section, or hospital wide. Good program. Its integrated into our EMR with possiblities of interlinking (to antibiotic protocols of institutions, or departments or nursing protocols). Teams can build it and amend it and there is one protocol holder (responsible)

This is always a difficult problem to tackle. There is no easy answer but I think it lies in multiple steps:
1] set clear expectations, common goal, but also a boundery system that aligns with internal motivation of people
2] measure outcome and share team (average) performance/success with everbody (I would not compare individual performance)
3] have annual reviews on individual motivation (in particular barriers or causes of unhappiness), goals, and performance. Implement tools like 360 degree reviews, etc to establish feedback channels
4] give immediate (documented) feedback if bounderies are crossed
5] involve HRM actively..

This was also a problem in the Netherlands. Most E.R’s in the Netherlands now have a GP / PCP post (also staffed during out of office hours) at the hospital that liaises with patients own PCP via standardized PCP EMR. Patients are being triaged at the hospital gate by a triage nurse for the PCP post or E.R. There is also financial incentive for patients to go to PCP post. There is a copayment (own risk) for E.R. / hospital visits but PCP visits are fully reimbursed (also the PCP post at the hospital).