Effect evaluation of competency-based education (CBE) combined with multi-disciplinary team (MDT) teaching mode in respiratory rehabilitation nursing teaching：A randomized controlled trial

AIM

To explore the application effect of competency-based education (CBE) combined with multi-disciplinary team (MDT) teaching mode in respiratory rehabilitation nursing teaching.

BACKGROUND

Respiratory rehabilitation, as an important non drug treatment for chronic respiratory disease, started late in China, with low implementation rate in hospitals and insufficient knowledge of nursing staff. Therefore, it is urgent to cultivate high professional level nurses with strong professional ability.

DESIGN

A randomized controlled trial.

METHODS

We selected nurses from the respiratory and critical care department at a Grade III, Level A hospital in Beijing, who participated in the respiratory rehabilitation training program between March 2020 and August 2022, as our study participants. Participants were grouped using a random number method. Nurses who participated in the study from March 2020 to May 2021 were set as the control group, and the nurses who participated in the study from June 2021 to August 2022 were set as the test group. The control group used traditional teaching methods, and the test group used the CBE combined MDT teaching model. At the end of the test, the theory, operating skills, satisfaction and core competence were assessed.

RESULTS

After training, the theoretical examination score of the test group (93.71 ± 1.94) was higher than that of the control group (92.37 ± 1.92), the operational examination score of the test group (93.11 ± 2.12) was higher than that of the control group (91.61 ± 1.93), the overall teaching satisfaction of the test group (4.45 ± 0.50) was higher than that of the control group (4.13 ± 0.57), and the total score of the core competence of the test group (148.73 ± 7.08) was higher than that of the control group (141.02 ± 6.41). The difference between the two groups was statistically significant (P<0.05).

CONCLUSION

CBE combined with MDT teaching mode has a good effect in Pulmonary and Critical Care Medicine (PCCM) respiratory rehabilitation nursing teaching.

Lung Cancer resection in the absence of pre-operative histology: The Accuracy of Multidisciplinary Team Consensus

BACKGROUND

Lung resection remains the gold-standard of treatment for non-small cell lung cancer (NSCLC). British Thoracic Society (BTS) guidelines recommends the pursuit of pre-operative histological diagnosis and staging where possible. In the absence of pre-operative histology, surgical treatment can be offered in conjunction with multidisciplinary team (MDT) and patient consensus. We undertook a single-centre analysis of the accuracy of the lung cancer MDT in recommending surgical resection for those with suspected lung malignancy in the absence of pre-operative histological diagnosis over a six-year period.

METHODS

A retrospective review was performed of patients undergoing any pulmonary oncological resection with therapeutic intent without pre-operative histological diagnosis at the recommendation of the lung cancer MDT in our unit between May 2016 and July 2022.

RESULTS

270 consecutive patients underwent lung resection for a lung nodule of indeterminate significance. This accounted for 45% of the oncological resections performed over this period. The mean age of the cohort was 67.9 years, and 47.4% were male. Overall, 10% of resected specimens (n = 27) were benign on final histopathology. 93% of those undergoing a lobectomy received a malignant diagnosis. Across the study cohort, surgical resection was well tolerated with a low complication rate.

CONCLUSIONS

Lung cancer resection in the absence of pre-operative histological diagnosis is feasible in a select patient cohort. This approach requires an experienced multi-disciplinary team and careful patient counselling. Our study demonstrates this adapted approach to be a pragmatic solution to the management of indeterminate pulmonary nodules in centres where biopsy is not routinely available due to existing constraints on the health system.

Impact of regional multi-disciplinary team on the management of complex urogynaecology conditions

INTRODUCTION AND HYPOTHESIS

Following the publication of the National Institute for Health and Care Excellence guidelines on the management of pelvic floor dysfunction, articles speculating on the benefits and costs of local and regional multi-disciplinary teams (MDTs) have been in circulation. To date, there has been no formal assessment of the impact of a regional MDT on the management of women with complex urogynaecological conditions.

METHODS

Throughout the existence of the West of Scotland (WoS) Regional Urogynaecology MDT, from May 2010 to December 2015, 60 patients with complex Urogynaecology conditions were discussed. Data were collected on presenting condition, pre- and post-MDT management plans, and treatment outcomes.

RESULTS

The average age was 52.6 years (range 21-91 years). All meetings had at least 1 urogynaecologist, 1 gynaecologist, 1 reconstructive female urologists, 1 urodynamicist and, on average, 3 continence nurses, 4 physiotherapists, as well as 1 clinical librarian to conduct a literature search and 1 secretary for administrative support. The majority of the referrals dealt with urinary incontinence (n=34) and 8 patients presented with mesh complications alongside other pelvic floor disorders. The MDT made changes to the original referrer's management plan in at least 25 (41.7%) patient presentations. Twenty-two out of all the patients discussed (36.7%) were reported as cured or improved in their condition following the MDT-recommended management.

CONCLUSION

The WoS Regional Urogynaecology MDT had a positive impact on the management of women presenting with complex condition(s). Cross-sharing of resources between hospitals within the region provided a wider range of management plans, better tailored to each individual.

Development of a coordinated acute diabetic foot pathway for management of acute diabetic foot infection and ulceration

BACKGROUND

Diabetic foot ulceration (DFU) has become an increasingly common emergency presentation. These patients are presenting at a younger age and with increasingly complex co-morbidities. They require frequent hospitalisation for management of DFU which has significant consequences for management of health resources but also for quality of life in the diabetic patient population.

AIM

The aim of this study was to evaluate the impact of the development of a coordinated, streamlined acute diabetic foot pathway for management of in-patients presenting as emergencies with DFU on length of stay, re-admission to hospital and minor and major amputations.

METHODS

A dedicated acute diabetic foot pathway was introduced to St. Vincent's University Hospital (SVUH) in April 2016. Management of patients admitted urgently to the emergency department or out-patient clinics of St. Vincent's University Hospital during the 3-year period before April 2016 was compared to that of patients admitted in the 3 years after April 2016 following introduction of the acute diabetic foot pathway. Demographic data hospital length of stay, need for re-admission, major and minor amputations performed and cost of hospital stay were compared before and after introduction of the pathway.

RESULTS

There were 931 admissions with acute diabetic foot ulceration or infection between January 2012 and December 2019; 419 were admitted between January 2012 and March 2016 and 512 between April 2016 and December 2019. There was no difference in demographic data between the two time periods. Length of stay decreased from 13 +/- 4.24 to 3 +/- 1.41 days between the two time periods (p < 0.001). Re-admission rates within 30 days decreased from 21.7 to 10.1% (p < 0.05). The number of major lower limb amputations decreased over the two time periods from 8.8 to 7.2% with a concomitant increase in minor amputations from 16.7 to 25.3%. Risk of major lower limb amputation was significantly higher in those patients living more than 20 km from the hospital. Costs associated with in-patient stay for management of DFU decreased from €9,247,700 to €8,988,100 despite an 18% increase in the number of patients treated and a 9.9% increase in hospital admissions.

CONCLUSION

Introduction of a dedicated, streamlined pathway involving multi-disciplinary input resulted in a significant improvement in patient management as assessed by length of hospital stay and need for re-admission. While the number of major lower limb amputations has decreased there has been a significant increase in the number of minor amputations.

Integration of palliative care in the management of oral squamous cell carcinoma

Oral Squamous cell Cancers (OSCC) is strongly associated with tobacco consumption. We here in present a case study of a OSCC patient who refused standard oncological care (SOC), to highlight the importance of integrating palliative care (PC) for improved patient outcomes. A 61 years male patient, with history of chewing tobacco for more than 20 years and diagnosed to have OSCC for 1.5 years presented with severe anaemia and a cauliflower-like growth (12 x 10 cm) in the left oral cavity and cheek with greenish-yellow discharge. Pus culture was positive for K. pneumoniae and P. aeruginosa. Patient is also a known hypertensive for 15 years and a diabetic for 7 years on allopathic treatment. However, the patient refused SOC for oral cancer and relied on siddha treatment. Packed cell transfusions were given to correct anaemia and the blood glucose levels was kept under control. Frequent wound debridement, oral care, antibiotics, balanced-diet and hydration improved wound-bed granulation. Patient and family members were counselled and explained in detail on the need for SOC by sharing previous OSCC patients' care and outcomes at our centre. Patient gained trust and courage and agreed for chemotherapy, which reduced the disease burden and improved the quality of life (QoL) considerably. Therefore, PC integration at an early stage of treatment is imperative as it reduced (i) the burden of secondary infection, (ii) pain and distress, and (iii) improved the QoL.

[Chinese multidisciplinary expert consensus on combined immunotherapy for hepatocellular carcinoma(2023 version)]

Immune checkpoint inhibitors (ICIs)-based immunotherapy combined with other treatment for hepatocellular carcinoma (HCC) has achieved significant efficacy in clinical research and practice, and has become the most commonly used and mainstay therapy for the treatment of unresectable HCC. In order to help clinicians administrating immunotherapy drugs and regimens rationally, effectively and safely, we organized a multidisciplinary expert team to adopt the "Delphi" consensus formation method, and finally revised and completed the "Multidisciplinary Expert Consensus on Combination Therapy Based on the Immunotherapy for Hepatocellular Carcinoma (2023 Edition)" on the basis of the 2021 version. This consensus mainly focuses on the principles and methods of clinical application of combination therapy based on the Immunotherapy, aiming to summarize the recommendations for clinical application based on the latest research and expert experience, and provide application guidance for clinicians.

Implementing service transformation for children and adolescents with eating disorders across England: the theory, politics, and pragmatics of large-scale service reform

BACKGROUND

Eating disorders are among the most serious mental health problems affecting children and young people and without appropriate treatment often have a protracted course with high levels of morbidity and mortality. While considerable progress has been made in recent years in developing effective evidence-based outpatient treatments, these are not always readily available. In England, until recently, the usual care pathway for young people with an eating disorder was referral from primary care to local generic Child and Adolescent Mental Health Services with varying levels of expertise in eating disorders and a mix of outpatient treatments available. Poor treatment progress or physical deterioration would usually result in inpatient admission. Admission rates were high, with children and young people with an eating disorder accounting for nearly a quarter of all child and adolescent psychiatric hospital admissions. Inpatient treatment is costly and has high relapse rates with some evidence that it may contribute to poorer long-term outcomes in eating disorders. Accumulating clinical and research evidence that early expert outpatient treatment can significantly reduce the need for inpatient care indicates,+ that investing in dedicated community-based eating disorders services is likely to be both clinically and economically beneficial.

OVERVIEW OF PAPER

This paper describes a large-scale transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community-based eating disorders services for children and young people.

Early introduction of the multi-disciplinary team through student Schwartz Rounds: a mixed methodology study

BACKGROUND

Medical education has changed continually throughout the covid-19 pandemic, creating additional stress for medical students. Personal reflection can empower an individual to adapt to new challenges, and reflection has gradually become incorporated into medical student training. Schwartz Rounds (SR) offer a compassionate group reflective forum for healthcare staff. SRs have been extensively introduced throughout the NHS, however medical student rounds are yet to be widely adopted. Entirely unresearched is how the multi-disciplinary team impacts a medical student SR. This study aims to compare medical student experience of a single-discipline and a multi-discipline SR using mixed methodology.

METHODS

Two virtual SRs were run at an NHS district general hospital, using the existing structure of the Trust's rounds. The first round included only medical students on placement at the hospital, whereas the second round also involved other student health disciplines. Following each round Likert scale questionnaires were collected, and focus groups were held with a small number of participants. Quantitative analysis used median averages as well direct comparison of scores for each round. Qualitative data from the focus groups underwent thematic analysis.

RESULTS

The quantitative data showed a positive response to both styles of student SRs, with over 87% of participants at both rounds stating they intended to attend further rounds. Direct comparison between the two rounds showed higher feedback scores for the single-discipline round. Qualitative analysis showed strong student interest in further group reflection, noting the value of SRs in improving workplace culture and inter-professional relationships. The analysis also highlighted frustrations with the existing SR structure, namely large group sizes and scripted panellists.

CONCLUSIONS

Both data sets showed a strong positive response to SRs, and a desire to attend again. There is some evidence to suggest the addition of multiple student disciplines at SRs impaired medical student reflection. Changes to the format of the round could result in even greater success in student rounds.

Ductal adenocarcinoma of the prostate or seminal vesicle adenocarcinoma: An multi-disciplinary team (MDT) case report and literature review

We introduced a 61-year-old male with ductal adenocarcinoma of the prostate who underwent a tortuous diagnosis and treatment. Multi-disciplinary team meetings organized by our hospital have shown great value in the whole process. The patient presented with gross hematuria accompanied by frequent urination initially, and was diagnosed with ductal adenocarcinoma of the prostate involving right seminal vesicle gland and urethra by urethroscopy biopsy. The clinical stage of tumor was T3bN0M0. After 4 cycles of neoadjuvant chemotherapy, the tumor shrank significantly and the patient underwent a laparoscopic radical prostatectomy. But the patient declined to continue chemotherapy postoperatively. After 10 months, the serum prostatic specific antigen increased to 0.05 ng/mL, and multiple metastases were found in the patient's bilateral lungs. However, an unexpected diagnosis of seminal vesicle adenocarcinoma was put forward from another hospital after supplementary pathologic immunohistochemical examination. Then, after careful discussion and demonstration by our multi-disciplinary team experts, we insisted on the diagnosis of ductal adenocarcinoma of the prostate and suggested that the original regimen of chemotherapy should be continued. Up-to-date, 14 months after the operation, the patient continues to survive while undergoing ongoing active treatment as recommended.

Improved outcomes for patients undergoing colectomy for acute severe inflammatory colitis by adopting a multi-disciplinary care bundle

PURPOSE

Severe inflammatory colitis as a consequence of inflammatory bowel disease (IBD) may not be amenable to medical management, and surgery is often required. The optimal timing of surgery and perioperative therapeutic care requires a formal link between surgical department and gastroenterology which is often lacking. In this study, we assess the impact of adopting a multidisciplinary care bundle on complication rates of subtotal colectomy in IBD patients.

METHODS

This is a single-centre retrospective observational study. Patients were identified through clinical discharge ICD10 codes. Clinical notes of patients who underwent subtotal colectomies from 1 January 2006 to 31 December 2019 were analysed. Socio-demographics, diagnosis, and medical and surgical management data were collected. A multimodule bundle, including weekly MDT discussions, was started in our unit on 1 April 2014. Multivariable logistic regression analysis was performed on these data.

RESULTS

A total of 296 patients were identified with 113 patients of these (38.2%) experiencing a complication post operation. The overall complication rate improved over time (p = 0.023). Those patients treated after the initiation of the MDT bundle had reduced complication rates (44.6% versus 33.7%, p = 0.045). On multivariate analysis, increasing age (1.023 OR; 95% CI 1.004, 1.041) and procedure performed before MDT bundle (3.1 OR; 95% CI 1.689, 5.723) were independent predictors for post-operative complications.

CONCLUSIONS

Closer links between gastroenterology and colorectal specialties have improved patient outcomes in our unit. Whilst IBD MDTs have previously been shown to improve outcomes for patients managed medically, we demonstrate that this interaction, implemented as a multidisciplinary care bundle, also improves surgical outcomes.

Core curriculum in pathology for future Irish medical students

Pathology is important in training to become a medical doctor but as curricula become more integrated, there is a risk that key aspects of pathology may be excluded. Following a survey of the current delivery of teaching in Ireland under the auspices of the Faculty of Pathology at the Royal College of Physicians of Ireland, suggested components of a core curriculum in pathology have been developed to be delivered at some stage during the medical course. These have been based on key principles and themes required by the Medical Council in Ireland. Professionalism is one of the core principles emphasised by the Medical Council. It includes the role of the pathologist in patient care and other professional values such as patient-centred care, clinical competencies and skills, e.g. explaining results, and knowledge under the various sub-disciplines, i.e. histopathology (including neuropathology), clinical microbiology, haematology, chemical pathology and immunology. In each of these, we suggest key aspects and activities that the medical graduate should be comfortable in carrying out. The methods of delivery of teaching and assessment across pathology disciplines have evolved and adapted to recent circumstances. Lessons have been learned and insights gained during the COVID-19 pandemic as educators have risen to the challenge of continuing to educate medical students. Integrated and multi-disciplinary teaching is recommended to reflect best the professional environment of the medical graduate who works as an integral part of a multi-disciplinary team, with the minimum dependence on the traditional lecture, where at all possible. Finally, options on assessment are discussed, e.g. multiple-choice questions, including their respective advantages and disadvantages.

How is the reporting radiographer role portrayed in published studies? A scoping review

OBJECTIVES

Radiographers have been undertaking reporting tasks since the 1980's with a wealth of evidence published to support this practice. Radiographers have since developed skills in reporting all body systems, from all referral sources across a range of modalities. Radiographer reporting is now considered established and demand for radiographers in this role is rising to meet service demand. Reporting radiographers work as part of multi-professional image reporting teams, it is unclear how the radiographer role is perceived as part of this model. The aim was to review peer-reviewed literature to evaluate how the role of the reporting radiographer is portrayed and how the relationship between the two imaging professions has developed.

KEY FINDINGS

Language used to discuss the role of the reporting radiographer has changed over time. There is progress demonstrated from the practice of radiographer reporting being considered contentious or opposed to accepted and established. Recent publications focus on the importance utilising the skills of all multi-disciplinary team members in workforce structure. This features prominently when discussing future workforce design, such as with the Cancer workforce strategy and the development of the national standards for musculoskeletal reporting.

CONCLUSION

Published literature has highlighted a move towards acceptance of the reporting radiographer role. Multi-disciplinary team working, utilising the skills of all imaging team members, is essential to the success and sustainability of the imaging workforce moving forwards.

IMPLICATIONS FOR PRACTICE

Reporting by radiographers is established and will be prominent in the reporting workforce as part of long-term workforce planning, considering skills mix to form effective and sustainable multidisciplinary reporting teams.

Multi-disciplinary approach for the management of non-metastatic non-small cell lung cancer in the Middle East and Africa: Expert panel recommendations

The Middle East and Africa (MEA) region, a large geographical area, lies at the confluence of Asian, Caucasian and African races and comprises of a population with several distinct ethnicities. The course of management of non-small cell lung cancer (NSCLC) differs as per patients' performance status as well as stage of disease, requiring personalized therapy decisions. Although management of NSCLC has received a significant impetus in the form of molecularly targeted therapies and immune therapies in last few years, surgery remains gold standard for patients with early-stage disease. In case of unresectable disease, radiotherapy and chemotherapy are the primary management modalities. With newer therapies being approved for treatment of early stage disease, use of multi-disciplinary team (MDT) for comprehensive management of NSCLC is of prime importance. A group of experts with interest in thoracic oncology, deliberated and arrived at a consensus statement for the community oncologists treating patients with NSCLC in the MEA region. The deliberation was based on the review of the published evidence including literature and global and local guidelines, subject expertise of the participating panellists and experience in real-life management of patients with NSCLC. We present the proposed regional adaptations of international guidelines and recommends the MDT approach for management of NSCLC in MEA.

[New progress in the diagnosis and treatment of hepatocellular carcinoma: a decade of grinding sword]

Globally, hepatocellular carcinoma (HCC) is one of the most highly morbid, fatal, and malignant tumors, with a poor prognosis in advanced stage. In the past decade, new advances have been emerged in the field of HCC therapy, including surgery, ablation, transvascular intervention, external radiotherapy, and systemic therapy. Among them, systemic treatments, particularly targeted and immune checkpoint drugs have made outstanding progress, significantly improving the five-year survival rate of liver cancer patients. In addition, the management of liver cancer patients, especially the screening management and multidisciplinary collaborative diagnosis and treatment of high-risk populations, has significantly increased the early diagnosis rate and improved the overall treatment efficacy. Considering our country's condition and the development of existing treatment, the most effective strategy to reduce HCC mortality in the future is to accurately identify high-risk populations, increase the early diagnosis rate, and formulate personalized treatment strategies.

Sierra Leonean doctors' perceptions and expectations of the role of pharmacists in hospitals: a national cross-sectional survey

Background The effective implementation of pharmaceutical care requires pharmacists' collaboration with other healthcare providers, especially doctors. However, doctor's perceptions and expectations may not be in line with the tasks and responsibilities of pharmacists. Objectives We aim to explore doctors' expectations and perceptions of pharmacists while working together in a multi-disciplinary team in Sierra Leone. Setting Twelve public hospitals in Sierra Leone. Method A national cross-sectional survey was conducted between July and September 2018. Anonymous self-administered questionnaires were distributed to all doctors at randomly selected public hospitals. Data were analyzed in Excel and SPSS using descriptive and inferential statistics, and a p > 0.05 was taken as statistically significant. Main outcome measure Doctors' perceptions and expectations towards pharmacists role in patient care. Results A total of 119 out of 150 questionnaires were returned. Doctors hold a mixed perception of pharmacists. The majority of medical doctors believed that pharmacists are vital (n = 98; 82.4%) as they provide services that foster better patients outcomes (n = 78; 65.6%). However, about half (n = 58; 48.8%) expressed uncertainty or perceived pharmacists as incompetent in providing clinical pharmacy services. Our findings also showed a large proportion of doctors expect pharmacists to review medication order (n = 110; 92.4%) for appropriateness and monitoring patients' response to therapy and possible adverse drug effects (n = 112; 92.2%). M ore than three quarters (n = 104, 87.4%) were in favour of collaborating with pharmacists in the process of developing patients' treatment plans. Doctors (n = 116; 97.5%) were of the view that doctor-pharmacist collaborations can be improved by developing trust relationships through dialogue. No demographic characteristics were independently associated with doubt in pharmacist clinical competence. Conclusion Reservations regarding pharmacists' clinical competency still prevail amongst medical doctors. Conversely, they view pharmacists as crucial players in the healthcare delivery system in Sierra Leone. Doctors also have high expectations of pharmacists in terms of contributing to better patient outcomes and therefore wish to collaborate. Possible interventions to settle doctors' discontent regarding pharmacists may include fostering interprofessional training, practice, and constructive dialogue.

How to manage treatment failure in prosthetic joint infection

BACKGROUND

Management for prosthetic joint infections remains a challenging area for both infectious diseases and orthopaedic surgery, particularly in the setting of treatment failure. This is compounded by a lack of level 1 evidence to guide approaches. The optimal management of prosthetic joint infections requires a multi-disciplinary approach combined with shared decision making with the patient.

AIMS

This article describes the approach to prosthetic joint infections in the setting of treatment failure.

SOURCES

Narrative review based on literature review from PubMed. There was no time limit on the studies included. In addition, the reference list for included studies were reviewed for literature saturation with manual searching of clinical guidelines. Management approaches described incorporate evidence- and eminence-based recommendations from expert guidelines and clinical studies, where applicable.

CONTENT

The surgical and antimicrobial approaches for prosthetic joint infections are described for first-line treatment of prosthetic joint infections and approaches in the event of treatment failure. Management approaches are based on an understanding of the role the biofilm plays in the pathogenesis of prosthetic joint infections. The management of these infections aims to fulfil two key goals: to eradicate the biofilm-associated microorganisms and, to maintain a functional joint and quality of life. In treatment failure, these goals are not always feasible, and the role of the multi-disciplinary team and shared-decision making are prominent.

IMPLICATIONS

Prosthetic joint surgery is a high-volume surgery, and the demand for this surgery is continually increasing. With this, the number of infections requiring expert care will also increase. Eminence-based management approaches have been established to guide treatment failure until knowledge gaps in optimal management are addressed by well-designed, clinical trials.

The role of multidisciplinary decision making in oropharyngeal cancer: do we follow guidelines and are treatment decisions being implemented?

PURPOSE

A multidisciplinary team (MDT) approach to cancer management is gold-standard. With an increasing disease incidence and growing research into human papillomavirus (HPV)-related oropharyngeal cancer (OPC), updated UK management guidelines were recently published. This study aimed to evaluate the MDT decision-making process among OPC patients at a tertiary centre.

METHODS

MDT meetings over a 12-month period were analysed retrospectively. MDT decisions were compared with guidelines and patient records examined to identify decision implementation. Reasons behind any discordant decisions were explored.

RESULTS

This study included 140 OPC patients. Thirty-three (23.6%) were not tested for HPV. Patients over 70 years with a smoking history treated palliatively were less likely to be tested (P = 0.017). Eighty-five percent of MDT decisions followed guidelines with the majority not complying (76.2%) related to patient comorbidity. Ten decisions (7.1%) were not implemented. Reasons included: Seven due to patient choice, of which four patients (57.1%) were only seen following the MDT meeting, and three due to clinician decisions as new clinical information emerged.

CONCLUSION

The majority of MDT decisions followed guidelines and any discordant decisions were justifiable. Discussing management options with patients beforehand facilitates decision implementation as decisions can potentially change after seeing the patient. Progress is still needed with regards to HPV testing. Reasons for not testing could include subliminal decision-making among clinicians, and patients falling between centres. Crucially, the role of the MDT in head and neck cancer should be to ratify decisions rather than making them, hence the need to see patients prior to MDT discussion.

The multi-disciplinary team - Who is liable when things go wrong?

The question of culpability over decisions made by the multi-disciplinary team (MDT) is a contentious one. Currently, all members present remain responsible for the MDT's decision, but it is unclear whether the onus of decision making lies with the patient's "lead clinician", and how straight to test pathways (bypassing a consultation with a specialist prior to MDT discussion) impact on this. Additionally, should a non-consensus recommendation be reached, it remains undetermined how dissenting members of the MDT would be viewed in a court of law. Given these uncertainties, there remains a substantial risk of legal action against the MDT as a group. Until case law materialises to provide clarification on these issues, clinicians should improve their awareness over their medico-legal responsibilities and proceed with caution.

The management of agitation in adult critical care: Views and opinions from the multi-disciplinary team using a survey approach

OBJECTIVES

To better understand the current strategies employed to manage patient agitation by capturing the views and opinions of the multi-disciplinary team within general Adult Critical Care Units in the UK.

RESEARCH METHODOLOGY

Web-based questionnaire survey.

SETTING

General Adult Critical Care Units in one region of the United Kingdom MAIN OUTCOME: The online survey was circulated to approximately 900 members of staff at eight sites in the UK. The online survey was accessed by 239 (26.5%) clinicians, 163 (18.1%) completed the first two screening questions rendering them valid for inclusion. For those who responded, 98.5% acknowledge the increased risk of harm in the presence of agitation. Additionally, 76.3% felt the management of agitated patients could be improved. Many participants felt equipped in the recognition of delirium and agitation but did not feel they had the knowledge to support decision-making around acute agitation management. There is concern about the use of physical restraint and the over-reliance on sedation. There appears to be inconsistent care delivery exacerbated by staff rotational changes.

CONCLUSION

There are valid concerns raised surrounding the legality of physical restraint and what level of restrictive action is permissible. Currently, we have no robust evidence to determine the effectiveness of one intervention to prevent treatment interruption over another. There is a need to explore the clinical decision-making process that underpins the care of a patient experiencing agitation in Adult Critical Care.

Laparoscopic excision of deeply infiltrating endometriosis: a prospective observational study assessing perioperative complications in 244 patients

PURPOSE

To examine peri-operative complications in patients undergoing laparoscopic excision of deeply infiltrating endometriosis (DIE).

METHODS

This was a prospective study of a case series of women having laparoscopic excision of deeply infiltrating endometriosis from September 2013 through August 2016 in a tertiary referral center for endometriosis and minimally invasive gynaecological surgery in Iran. Data collected included demographics, baseline characteristics, intraoperative and postoperative data up to 1 month following surgery.

RESULTS

We analysed data from 244 consecutive patients, who underwent radical laparoscopic excision of all visible DIE. Major postoperative complications occurred in 3 (1.2%) and minor complications in 27 (11.1%) of patients. 80.3% of our patient group had Stage IV endometriosis. Segmental bowel resection was performed in 34 (13.9%), disc resection in 7 (2.9%), rectal shave in 53 (21.7%). Joint operating between a gynaecologist and colorectal and/or urological colleague was required in 29.6% of cases. The mean operating time was 223.8 min (± 80.7 standard deviation, range 60-440 min) and mean hospital stay was 2.9 days (± 1.5 standard deviation, range 1-11). The conversion to laparotomy rate was 1.6%.

CONCLUSIONS

A combination of different laparoscopic surgical techniques to completely excise all visible DIE, within the context of a tertiary referral center offering multi-disciplinary approach, produces safe outcomes with low complication rates.

Assessing the Impact of a Pulmonary Embolism Response Team and Treatment Protocol on Patients Presenting With Acute Pulmonary Embolism

BACKGROUND

Pulmonary embolism (PE) care has traditionally been fragmented. The newly introduced Pulmonary Embolism Response Team (PERT) model provides streamlined care based on expedient, multi-disciplinary decision-making. This study aimed to quantify the impact of PERT, as part of a hospital-wide PE treatment protocol, on clinical outcomes.

METHODS

Consecutive adult patients with acute PE diagnosed via computed tomography pulmonary angiogram (CTPA) were included. The PERT and treatment protocol were introduced in January 2015. Patient characteristics, therapies, quality measures of CTPA reporting, and clinical outcomes of PE patients treated for 2 years before and after implementation of these changes were evaluated. Primary endpoints were median length of stay in intensive care (ICU) and survival to discharge.

RESULTS

A total of 321 consecutive PE patients were enrolled, of which 154 (treated in 2013-2014) and 167 (2015-2016) patients formed the historical control and study groups, respectively. Implementation of the algorithm was associated with less variance in anticoagulation and improved reporting of right heart strain parameters on CTPA. The ICU stay was reduced from a median of 5 to 2 days (p < 0.01). Eligible massive PE patients receiving reperfusion increased from 30% to 92% (p = 0.01), with mean delay from diagnosis to reperfusion decreasing from 763 to 181 minutes (p < 0.01). Bleeding complications were not increased, but overall survival to discharge remained unchanged.

CONCLUSIONS

Introducing a PERT and treatment protocol reduced ICU stay, enhanced quality measures, and improved access of massive PE patients to reperfusion therapies, without increasing bleeding complications or health care costs.

[Analysis of prognostic factors on multidisciplinary team for diagnosis, treatment and prevention of hepatocellular carcinoma]

Objective: To analyze the prognostic factors on multidisciplinary team patients for diagnosis, and treatment of hepatocellular carcinoma. Methods: This retrospective study enrolled 132 HBsAg positive patients with HCC. MDT diagnostic approach was conducted at our hospital between 1 January 2015 and 31 December 2015, and all patients were followed up to 31 December 2017. Groups were arranged according to variables such as Barcelona stage, MDT compliance, and multidisciplinary combination therapy. TTP and OS were statistically analyzed. Results: The survival of the MDT compliance group was better than the non-compliance group. The difference in survival curves was statistically significant (χ(2) = 4.062, P < 0.05). The 1- and 2-year survival rates of the former group were 72.0%, 60.9%, and the latter was 64.3%, 40.3%. The survival of the combined treatment group was better than the non-combination group. The survival curves of the two groups were statistically significant (χ(2) = 9.502, P < 0.05), and they were independent influencing factors of survival (HR = 0.451, 95% CI, 0.210-0.968). The 1- and 2-year survival rates of the former group were 82.2% and 75.4%, and the latter was 63.1% and 44.6%. The median survival time of the follow-up group was 29.4 months, and the non-compliance and the uncombined group were 17.0 months. The difference was statistically significant (χ(2) = 13.336, P < 0.001). The median tumor progression time was 15.7 months in the combination group and 10.1 months in the non-compliance group (χ(2) = 7.263, P < 0.05). Conclusion: An advanced MDT compliance with implementation of multidisciplinary combination therapy may help to improve the prognosis of MDT patients with liver cancer.

Exploring the Patient-Reported Impact of the Pharmacist on Pre-bariatric Surgical Assessment

BACKGROUND

The effects of surgical procedures and the need for life-long nutrient supplementation may impact on medication regimes, requiring changes to dosage and formulation of medicines, which can be difficult for patients following surgery. Our pre-surgical assessment pathway involves a pharmacist with specialist knowledge of bariatric surgery, to help prepare patients for these changes.

OBJECTIVE

To explore the patient-reported impact of the specialist bariatric pharmacist in pre-surgical assessment.

SETTING

National Health Service Hospital, United Kingdom.

METHODS

A two phased, retrospective study design using participants recruited from pre-surgical clinic lists. The first phase consisted of confidential, face to face semi-structured interviews. A constant comparative analytic framework informed the construction of the second phase, which consisted of a confidential survey to test the generalizability of the findings with a larger cohort of patients.

RESULTS

A total of 40 participants (12 interviews, 28 surveys) were recruited to the study. The majority of participants were female (n = 33), mean age 50 years, mean pre-surgical weight 124 kg (n = 38). The most common comorbidity was type 2 diabetes. Participants on medication had at least one comorbidity, with the majority of conditions improved or eliminated after surgery.

CONCLUSIONS

The pre-surgical consultation with the pharmacist was highly valued by the participants, providing information and support which helped prepare for medication changes after bariatric surgery. Many felt that a post-surgical appointment with the pharmacist would provide support and improve compliance with vitamins and medications. Future research into the role of pharmacists in the bariatric multi-disciplinary team and patient support are recommended.

Multi-disciplinary team for early gastric cancer diagnosis improves the detection rate of early gastric cancer

Background

Gastric cancer is a frequent malignant tumor worldwide and its early detection is crucial for curing the disease and enhancing patients’ survival rate. This study aimed to assess whether the multi-disciplinary team (MDT) can improve the detection rate of early gastric cancer (EGC).

Methods

The detection rate of EGC at the Digestive Endoscopy Center, Affiliated Hospital, Zunyi Medical College, China between September 2013 and September 2015 was analyzed. MDT for the diagnosis of EGC in the hospital was established in September 2014. The study was divided into 2 time periods: September 1, 2013 to August 31, 2014 (period 1) and September 1, 2014 to September 1, 2015 (period 2).

Results

A total of 60,800 patients’ gastroscopies were performed during the two years. 61 of these patients (0.1%) were diagnosed as EGC, accounting for 16.44% (61/371) of total patients with gastric cancer. The EGC detection rate before MDT (period 1) was 0.05% (16/29403), accounting for 9.09% (16/176) of total patients with gastric cancer during this period. In comparison, the EGC detection rate during MDT (period 2) was 0.15% (45/31397), accounting for 23% (45/195) of total patients with gastric cancer during this period (P < 0.05). Univariate and multivariate logistic analyses showed that intensive gastroscopy for high risk patients of gastric cancer enhanced the detection rate of EGC in cooperation with Department of Pathology (OR = 10.1, 95% CI 2.39–43.3, P < 0.05).

Conclusion

MDT could improve the endoscopic detection rate of EGC.

Electronic supplementary material

The online version of this article (10.1186/s12876-017-0711-9) contains supplementary material, which is available to authorized users.

Re-organizing inpatient care saves legs in patients with diabetic foot infections

AIMS

In this study, we evaluated the effects of the re-organization of inpatient care for patients with a diabetic foot infection, and the implementation of a specialized multi-disciplinary wound department at an academic tertiary hospital.

METHODS

This was a retrospective cohort study, comprising 272 patients treated for diabetic foot infections in 2006-2007 (Group 1, n=124) and 2013-2014 (Group 2, n=148). In 2012, inpatient care of all chronic wounds was centralized at a single wound department with a multi-disciplinary team. We assessed group outcome before and after the re-organization.

RESULTS

During the 7-year study period, the incidence of hospitalized patients with a diabetic foot infection increased 19%. After initiating the re-organization, the below-the-knee amputation rate was significantly reduced (25.8% vs. 9.5%, p<0.001). The median time from admission to surgical intervention decreased from 5days to 2days, p<0.001. The length of hospitalization also tended to decrease after the reorganization.

CONCLUSIONS

The findings of this study demonstrate the benefits of treating diabetic foot infections at a specialized wound department with a multi-disciplinary team. The benefits were achieved by simply distributing the workload and organizing schedules, without new investments or additional personnel. The findings of this study indicate that patients with diabetic foot infections present a challenge that is beyond the expertise of a single field of medicine. A working collaboration between disciplines and a specialized wound department are central in achieving better results.

Discharge Planning: Screening Older Patients for Multidisciplinary Team Referral

The objective was to determine whether the Elders Risk Assessment Index can predict multi-disciplinary team referral of older patients (≥ 65 years) in Emergency Department same-day discharges.

The study identified 1,376 qualifying individuals from a regional New Zealand hospital database. Of these, 12.7 % were referred to the multi-disciplinary team. Univariate and multivariate analyses were used to explore associations between the Index, its components, and other demographic factors with referral. With every unit increase in the Index there was a 9% increase in the odds of being referred. When the components of the Index were analysed separately, an increased likelihood of being referred was associated with not being married, having had a previous hospital admission of more than five days, having chronic obstructive pulmonary disease, and being older. Conversely, a decreased likelihood was associated with having diabetes. When non-Index items were analysed it was found that females were more likely to be referred than males and that Māori were less likely to be referred than New Zealand Europeans.

With adaptation, the Elders Risk Assessment Index may provide a simple, cost-effective, and timely tool to assist in determining the need for multi-disciplinary team referral for older people who present to the Emergency Department.

Overcoming communication challenges in integrative supportive cancer care: The integrative physician, the psycho-oncologist, and the patient

BACKGROUND

Complementary/integrative medicine (CIM) services are increasingly being integrated into conventional supportive cancer care, presenting a number of challenges to communication between healthcare professionals (HCPs). The purpose of the present study was to explore the impact of the communication between integrative physicians (IPs) trained in CIM and social workers (SWs) working as psycho-oncologists in the same oncology setting. We examine whether IP-SW communication correlates with the number of patient-SW sessions, as provided within the oncology department.

METHODS

SW-IP communication, defined as a summary of the IP consultation sent to the patient's SW, was compared to SW-patient communication, defined as the number of psycho-oncology treatment sessions.

RESULTS

Of 344 patients referred by their oncology HCP for IP consultation, 91 were referred by an SW and 253 by an oncologist or nurse. IP-to-SW summaries were provided for 150 patients referred by a non-SW HCP (43.6%), and for 91 of SW-referred patients (26.5%). In all, 32 patients referred to the IP had no psycho-oncology interaction with an SW; 58 only one meeting; and 254 with ≥2 interactions, with 119 having >6 sessions. SW-patient interactions were greater with higher rates of IP-SW communication, for both patients referred by an SW (79.1%) and those referred by a non-SW HCP (77.3%) when compared to patients for whom no summary was provided (64.1%; p= 0.02).

CONCLUSION

A greater level of IP-SW communication, measured by the provision of an IP summary to the patient's SW, was found to correlate with a higher rate of SW-patient interactions. The use of a structured two-way referral-summary between IPs and SWs has the potential to advance the SW-patient psycho-oncology interaction, within an integrative supportive cancer care setting.

A case of small bowel mesenteric pneumatosis: A multidisciplinary approach to clinical interpretation and intervention

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Mesenteric pneumatosis of the small bowel is a very rare pathological sign.

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CT is the radiological investigation of choice to identify this sign.

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It is associated with significant morbidity such as small bowel obstruction and ischaemia.

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CT findings of mesenteric pneumatosis should be interpreted within a clinical context when a decision for surgical intervention is being considered

Introduction

Pneumatosis of the small bowel mesentery is rare and the preserve of case reports. This case report describes the importance of a multi-disciplinary team (MDT) approach to rare pathologies.

Case report

A 78-year-old man presented to our unit with a two-day history of upper abdominal pain associated with nausea and intermittent vomiting. An urgent computed tomography (CT) scan was organised. The scan was grossly abnormal and difficult to interpret; it was reported as widespread intra-mural gas within the small bowel wall most likely secondary to extensive small bowel ischaemia. Although surgical intervention was very high risk (predicted P-possum mortality of over 60%) and there was a strong possibility that the patient would not recover from surgery, the disparity between clinical and radiological findings meant that a diagnostic laparoscopy was indicated. A diagnostic laparoscopy showed that the small bowel itself was normal but there was extensive gas within the mesentery, caused by a band adhesion which had eroded into the peritoneal layer of the small bowel mesentery.

Discussion

Pneumatosis of the small bowel mesentery is a pathological sign rather than a diagnosis and is characterised by gas within the mesenteric sleeves. It is likely associated with significant morbidity and therefore rarely observed as the majority with this sign would not be deemed suitable for surgical intervention.

Conclusion

The case highlights an unusual pathology, rare imaging findings, the importance of a multi-disciplinary approach and the value of clear communication and informed consent when considering major intervention or surgery.

Self-inflicted Burns: 10 year review and comparison to national guidelines

INTRODUCTION

There is an increasing trend of self-inflicted burns noted in the literature, often seen in patients with complex psychosocial backgrounds. These patients are challenging to manage as the recovery from the acute burn may be compounded by difficult rehabilitation and suboptimal coping strategies. We aimed to review patients presenting to our burns unit with self-inflicted burns, the management strategies and examine the complexities surrounding their management. We assessed patient outcomes with a particular interest in psychosocial support given.

METHODS

A retrospective review of all patients presenting with self-inflicted burns over a 10 year period (2005-2014 inclusive) was conducted. Patients were identified through IBID database coded as either 'self-inflicted' or 'suicidal.' We reviewed patient and burn demographics, the clinical management, psychosocial management and patient outcomes such as wound healing, re-admission rates, and survival.

RESULTS

We identified 118 self-inflicted burns in total. 50/118 (42%) were admitted. 64 (54%) were male and the total body surface burn area ranged from <0.5% to 99% with a median of 14%. 60/118 (51%) had TBSA <10% and 58/118 (49%) had TBSA >10%. 24 (48%) underwent admission to the Burn Intensive Care Unit (BITU). All patients admitted to BITU had TBSA >10%. Of those admitted to BITU 6 were palliative, 18 had full resuscitation and surgical management. Of those 18 patients who had active treatment, 10/18 (56%) died. Mean total length of stay was 31 days, range 1-130 days. 9% of patients sustained injuries whilst being a current inpatient at a psychiatric institution. Of all patients reviewed, 16% (n=19) had a previous history of deliberate self-harm through burns. Of those patients admitted, 98% of were reviewed by the mental health team during their admission with time to psychological review varying depending on fitness for assessment. The overall mean length of stay for all admitted patients who were actively treated but who subsequently died was 53 days. 84% of admitted patients were managed surgically.

CONCLUSION

Self-inflicted burns patients would benefit from a more complex pathway of treatment as their management aims to achieve not only physical health but also psychological health. They would benefit from enhanced care to manage the acute burn but also psychiatric support to ensure patients do not re-offend.

Oligometastatic breast cancer: a shift from palliative to potentially curative treatment?

A distinctive subset of metastatic breast cancer is represented by the so called 'oligometastatic' disease, characterized by single/few detectable metastatic lesions. A more aggressive multidisciplinary approach can be considered in this patient population: available data report favorable results of 'radical' local therapy for limited metastatic disease at least in a subset of selected patients. Selection bias and the retrospective nature of data do not allow for generalization of the results: the use of such approaches must be individualized and managed within a multidisciplinary team of dedicated specialists. Improvement in surgical and radiation techniques, development of new tools to deliver local chemotherapy, and new procedures (i.e. cryosurgery, laser and microwave ablation) mandate careful evaluation of such single and combined modalities in controlled clinical trials. A more accurate identification of patients with limited metastases and better definition of treatment endpoints will also allow correct patient selection for locally aggressive therapies. This paper focusses on local treatment of the primary tumor and of the most frequent distant disease sites in the presence of oligometastatic disease.

Overcoming challenges in the management of primary ciliary dyskinesia: the UK model

Primary ciliary dyskinesia (PCD) is an autosomal recessive disease associated with bronchiectasis, chronic rhinosinusitis, infertility and situs inversus. Estimates of prevalence vary widely, but is probably between 1:10,000- 1:40,000 in most populations. A number of observational studies indicate that access to services to diagnose and manage patients with PCD vary both between and within countries. Diagnosis is often delayed and frequently missed completely. The prognosis of patients with PCD is variable, but evidence suggests that it is improved by early diagnosis and specialist care. This article briefly reviews the literature concerning PCD and the evidence that specialist care will improve healthcare outcomes. The article specifically refers to a new national service in the UK.

Incorporating person centred care principles into an ongoing comprehensive cancer management program: an experiential account

Recent research indicates a definite positive impact on treatment outcomes when an integrative approach that focuses on symptom control and quality of life is provided along with the standard therapeutic regimens. However implementation or practice of this approach is not seen widely due to the culture of medical training and practice. This article presents the initial development of a program for incorporating integrative care principles into an ongoing comprehensive cancer care program at a tertiary centre. The key purpose of the program being to develop, facilitate, and establish comprehensive and holistic processes including palliative care principles, that would positively enhance the quantity and quality of life of the person with disease, as well as create an environment that reflects and sustains this approach. The vision, objectives, goals, strategies, activities and results within the 7 months of implementation are documented. The new learnings gained during the process have also been noted in the hope that the model described may be used to conceptualize similar care giving facilities in other centres.

Nutritional approach to failure to thrive

Failure to thrive (FTT) is a term generally used to describe an infant or child whose current weight or rate of weight gains is significantly below that expected of similar children of the same age, sex and ethnicity. It usually describes infants in whom linear growth and head circumference are either not affected, or are affected to a lesser degree than weight. FTT is a common problem, usually recognized within the first 1-2 years of life, but may present at any time in childhood. Most cases of failure to thrive involve inadequate caloric intake caused by behavioral or psychosocial issues. The most important part of the outpatient evaluation is obtaining an accurate account of a child's eating habits and caloric intake. Routine laboratory testing rarely identifies a cause and is not generally recommended. FTT, its evaluation, and its therapeutic interventions are best approached by a multi-disciplinary team includes a nutritionist, a physical therapist, a psychologist and a gastroenterologist. Long term sequelae involving all areas of growth, behavior and development may be seen in children suffering from FTT. Early detection and early intervention by a multi-disciplinary team will minimize its long term disadvantage. Appropriate nutritional counseling and anticipatory guidance at each well child visit may help prevent some cause of FTT.