Prozessmanagement
Markus Zeige • 24. Oktober 2018
Von Modularität und Skalierbarkeit
Ein sinnvolles und möglichst umfassendes Prozessmanagement deckt diverse Bereiche ab, ohne dabei zu komplex zu werden. Deshalb zielt unser Prozessmanagement einerseits auf Modularität und andererseits auf Skalierbarkeit ab.
So müssen Sie nicht alles auf einmal umsetzen, sondern können sich von der Sinnhaftigkeit der Module einzeln überzeugen. Und Skalierbarkeit bedeutet für uns keine immensen Anfangskosten in Geschäftsmodelle, deren Tragfähigkeit ungewiss ist.
Schließlich muss das, was
bei einem Kollegen vor Ort funktioniert, nicht zwangsläufig bei einem Anderen
genauso funktionieren. Da ist es gut zu wissen, das man keine großen Beträge
aufbringen muss, um die Prozesse gerade am Anfang mit vielleicht weniger 50
Pflegepatienten sinnvoll zu managen.
Ich erhalte wöchentlich einen Newsletter mit neuen KI Modellen. Letzte Woche war eine der vorgestellten Apps Leny.ai - eine Medical AI Assistant. Eher skeptisch, wie profund er / sie wohl antworten wird, tippte ich einen Prompt zu einem Familienmitglied ein, welches an einer ausgeprägten Herzinsuffizienz leidet, mit eher atypischer Ödemverteilung. Das Ergebnis machte mich sprachlos. Lesen Sie selbst: You: 82 year old woman suffering form water in stomach area accompanied by nauseaness due to a severe heart insufficiency. Using Torasemid is solving the problem on the one hand but leads to massive dehyration of brain area on the other hand. What do you suggest how to balance this out? Leny: I suggest the following steps to balance the use of Torasemid and avoid dehydration of the brain area: 1. Review the current dose of Torasemid and consider reducing it to the lowest effective dose. According to the European Society of Cardiology guidelines for the management of acute and chronic heart failure, the initial dose of Torasemid in heart failure patients is usually 5-10 mg once daily, which may be increased up to 20-40 mg daily if needed. However, the dose should be individualized based on the patient's renal function and response to treatment. 2. Monitor the patient's fluid and electrolyte balance regularly, especially potassium and sodium levels. Hypokalemia (low potassium) can cause adverse effects on the brain, such as confusion and weakness. Therefore, it is important to ensure that the patient's potassium levels are within the normal range (3.5-5 mmol/L) and supplement it if needed. 3. Consider adding a potassium-sparing diuretic, such as Spironolactone or Eplerenone, to the treatment regimen. These drugs can help to reduce fluid retention and edema while minimizing the risk of electrolyte imbalances and dehydration. However, they should be used with caution in patients with renal impairment or hyperkalemia. 4. Evaluate the need for other medications that may exacerbate dehydration or electrolyte imbalances, such as non-steroidal anti-inflammatory drugs (NSAIDs) or ACE inhibitors. These drugs should be avoided or used with caution in patients with heart failure and renal impairment. 5. Consider non-pharmacological interventions to manage fluid overload, such as dietary sodium and fluid restriction, elevation of the legs, and use of compression stockings. These measures can complement the use of diuretics and help to improve symptoms and quality of life. You: Follow up question: Would you consider the usage of digitoxin to empower the heart beat? Leny: The use of digitoxin (a cardiac glycoside) in heart failure patients can be considered in certain situations when other treatments have failed or are not suitable. However, it should be used with caution and under close monitoring due to its narrow therapeutic index and potential toxicity. Here are some points to consider: 1. Digitoxin works by increasing the contractility of the heart muscle, which can improve cardiac output and symptoms in heart failure patients. However, it also has potential toxic effects on the heart, such as arrhythmias, and on other organs such as the brain and kidneys. 2. The use of digitoxin requires careful assessment of the patient's renal function, electrolyte levels (especially potassium), and concomitant medications that may interact with it or increase the risk of toxicity. 3. Other treatments, such as diuretics and ACE inhibitors/ARBs, should be optimized before considering the use of digitoxin. 4. The recommended doses of digitoxin in heart failure patients are lower than those used for arrhythmias, and the drug levels should be carefully monitored to avoid toxicity. The usual maintenance dose of digitoxin is 0.125-0.25 mg daily, but it may be lower in elderly patients or those with renal impairment. 5. The use of digitoxin in heart failure patients is not supported by strong clinical evidence, as most of the studies were conducted before the era of modern heart failure treatments and did not show significant improvement in survival or hospitalization rates. Therefore, its use should be individualized and based on the patient's clinical status and response to treatment. In summary, the use of digitoxin in heart failure patients should be considered carefully, taking into account the potential benefits and risks, and under close monitoring. It should be reserved for cases where other treatments have failed or are not suitable. You: What other positive ionotrope drugs would you recommend instead? Leny: There are several positive inotropic drugs that can be used in heart failure to improve cardiac function and symptoms. These drugs work by increasing the contractility of the heart muscle and improving cardiac output. Here are some examples: 1. Dobutamine: This is a synthetic catecholamine that acts primarily on beta-1 adrenergic receptors in the heart to increase contractility and heart rate. It is usually given intravenously and can be titrated to achieve the desired hemodynamic effect. Dobutamine is commonly used in acute heart failure or decompensated chronic heart failure. 2. Milrinone: This is a phosphodiesterase-3 inhibitor that increases intracellular levels of cyclic AMP, leading to increased contractility and vasodilation. It is given intravenously and can be used in acute or chronic heart failure, especially when there is concurrent pulmonary hypertension. 3. Levosimendan: This is a calcium sensitizing agent that enhances the sensitivity of cardiac myofilaments to calcium, leading to increased contractility. It also has vasodilatory effects and can improve diastolic function. Levosimendan is given intravenously and is approved for use in acute heart failure, especially in patients with low cardiac output or cardiogenic shock. 4. Digoxin: This is a cardiac glycoside that increases contractility by inhibiting the sodium-potassium ATPase pump, leading to increased intracellular calcium levels. It also has other effects, such as slowing heart rate and improving diastolic function. Digoxin is given orally and is usually reserved for patients with atrial fibrillation or when other treatments have failed. It is important to note that these drugs have different mechanisms of action, pharmacokinetics, and side effect profiles, and their use should be individualized based on the patient's clinical status and response to treatment. Combination therapy may also be considered in some cases to achieve optimal hemodynamic and clinical outcomes. You: Would you prefer the usage of Digoxin over Digitoxin? Leny: The choice between digoxin and digitoxin in heart failure patients depends on several factors, including the patient's age, renal function, and comorbidities, as well as the potential drug interactions and side effects. Here are some points to consider: 1. Both digoxin and digitoxin are cardiac glycosides that have similar mechanisms of action and therapeutic effects in heart failure. However, they have different pharmacokinetics and dosing regimens. Digitoxin has a longer half-life and is given once daily, whereas digoxin is given once or twice daily and has a shorter half-life. 2. The use of digoxin is supported by more clinical evidence than digitoxin, as it has been extensively studied in large randomized trials, such as the DIG trial and the AFFIRM trial. These studies showed that digoxin can improve symptoms, quality of life, and hospitalization rates in heart failure patients, especially those with atrial fibrillation. 3. The use of digitoxin is limited by its potential toxicity and narrow therapeutic index, which requires careful monitoring of drug levels and electrolytes. Digitoxin also has a higher risk of drug interactions than digoxin, as it is metabolized by CYP3A4 and Pglycoprotein. 4. The recommended doses of digoxin and digitoxin differ, with digoxin usually given at a lower dose than digitoxin (0.125-0.25 mg daily vs. 0.1-0.2 mg daily). The dose should be adjusted based on the patient's age, renal function, and lean body weight. In summary, the choice between digoxin and digitoxin in heart failure patients should be individualized based on the patient's clinical status and characteristics, as well as the potential risks and benefits of each drug. Digoxin is generally preferred over digitoxin due to its better safety profile, lower risk of drug interactions, and stronger clinical evidence. However, in certain situations, such as renal impairment or intolerance to digoxin, digitoxin may be considered as an alternative. References: 1. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(27):2129-2200. 2. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136(6):e137-e161.
