Improving morbidity and mortality in hip fragility fractures

PURPOSE OF REVIEW

Hip fragility fractures (HFF) carry high morbidity and mortality for patients and will increase in frequency and in proportion to the average patient age. Provision of effective, timely care for these patients can decrease their morbidity and mortality and reduce the large burden they place on the healthcare system.

RECENT FINDINGS

There are associative relationships between prefracture frailty, postoperative delirium and increased morbidity and mortality. The use of a multidisciplinary approach to HFF care has shown improved outcomes in care with focus on modifiable factors including admission to specialty care floor, use of peripheral nerve blocks preoperatively and Anesthesia and Physical Therapy involvement in the care team. Peripheral nerve blocks including pericapsular nerve group (PENG) blocks have shown benefit in lowering morbidity and mortality.

SUMMARY

HFF are associated with >40% chance of continued pain and inability to return to prefracture functional status at 1 year as well as >30% mortality at 2 years. In this opinion piece, we will discuss how a multidisciplinary approach that includes Anesthesia as well as utilization of peripheral nerve blocks can help to lessen postoperative issues and improve recovery.

Continuity of care for children with anorexia nervosa in the Netherlands: a modular perspective

Care provision for children with anorexia nervosa is provided by outpatient care teams in hospitals, but the way these teams are organized differs per hospital and hampers the continuity of care. The aim of this study is to explore the organization and continuity of care for children with anorexia nervosa in the Netherlands by using a modular perspective.We conducted a qualitative, exploratory case study and took the healthcare provision for children with anorexia nervosa, provided by outpatient care teams, as our case. We conducted nine interviews with healthcare professionals involved in outpatient care teams from six hospitals. A thematic analysis was used to analyze the data.The modular perspective offered insights into the work practices and working methods of outpatient care teams. We were able to identify modules (i.e. the separate consultations with the various professionals), and components (i.e. elements of these consultations). In addition, communication mechanisms (interfaces) were identified to facilitate information flow and coordination among healthcare professionals. Our modular perspective revealed gaps and overlap in outpatient care provision, consequently providing opportunities to deal with unnecessary duplications and blind spots.   Conclusion: A modular perspective can be applied to explore the organization of outpatient care provision for children with anorexia nervosa. We specifically highlight gaps and overlap in healthcare provision, which in turn leads to recommendations on how to support the three essential parts of continuity of care: informational continuity, relational continuity, and management continuity. What is Known: • Care provision for children with anorexia nervosa requires a network of health care professionals from different organizations, as a result the organization and provision of care faces challenges. What is New: • Modular care provision sheds light on the complexity and organization of outpatient care provision and supports the three dimensions of continuity of care as experienced by children with anorexia nervosa and their parents/caregivers.

Non-dispensing pharmacists integrated into general practices as a new interprofessional model: a qualitative evaluation of general practitioners' experiences and views

BACKGROUND

A new interprofessional model incorporating non-dispensing pharmacists in general practice teams can improve the quality of pharmaceutical care. However, results of the model are dependent on the context. Understanding when, why and how the model works may increase chances of successful broader implementation in other general practices. Earlier theories suggested that the results of the model are achieved by bringing pharmacotherapeutic knowledge into general practices. This mechanism may not be enough for successful implementation of the model. We wanted to understand better how establishing new interprofessional models in existing healthcare organisations takes place.

METHODS

An interview study, with a realist informed evaluation was conducted. This qualitative study was part of the Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in primary care Teams (POINT) project. We invited the general practitioners of the 9 general practices who (had) worked closely with a non-dispensing pharmacist for an interview. Interview data were analysed through discussions about the coding with the research team where themes were developed over time.

RESULTS

We interviewed 2 general practitioners in each general practice (18 interviews in total). In a context where general practitioners acknowledge the need for improvement and are willing to work with a non-dispensing pharmacist as a new team member, the following mechanisms are triggered. Non-dispensing pharmacists add new knowledge to current general practice. Through everyday talk (discursive actions) both general practitioners and non-dispensing pharmacists evolve in what they consider appropriate, legitimate and imaginable in their work situations. They align their professional identities.

CONCLUSIONS

Not only the addition of new knowledge of non-dispensing pharmacist to the general practice team is crucial for the success of this interprofessional healthcare model, but also alignment of the general practitioners' and non-dispensing pharmacists' professional identities. This is essentially different from traditional pharmaceutical care models, in which pharmacists and GPs work in separate organisations. To induce the process of identity alignment, general practitioners need to acknowledge the need to improve the quality of pharmaceutical care interprofessionally. By acknowledging the aspect of interprofessionality, both general practitioners and non-dispensing pharmacists will explore and reflect on what they consider appropriate, legitimate and imaginable in carrying out their professional roles.

TRIAL REGISTRATION

The POINT project was pre-registered in The Netherlands National Trial Register, with Trial registration number NTR-4389.

Overcoming Barriers to Collaborative Team Practice: A System Approach

All healthcare systems are challenged to provide sufficient access to appropriate care for the individuals and communities they serve. Among the commonly discussed interventions in an era of clinical shortages is the establishment of team-based care, where team members can practice at the top of their license. This solution ensures that talent and ability are amplified. However, this vision has been thwarted by several barriers. Recognizing that complex causes prevent team-based care, CommonSpirit Health leadership has embarked on a multifaceted implementation of tactics to mitigate the barriers. The strategy addresses issues ranging from regulations, laws, and payment practices to a lack of knowledge and understanding between professions. A combination of solutions, rather than discrete tactics, holds the key to the system's strategy. The complement of actions put in place at CommonSpirit Health has included new executive roles, dyad leadership models, shared multidisciplinary education, targeted advocacy, best practice playbooks, and the flexibility to individualize local models as part of the journey to a more effective and efficient model of care.

Nurse and Social Worker Palliative Telecare Team and Quality of Life in Patients With COPD, Heart Failure, or Interstitial Lung Disease: The ADAPT Randomized Clinical Trial

Importance

Many patients with chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) endure poor quality of life despite conventional therapy. Palliative care approaches may benefit this population prior to end of life.

Objective

Determine the effect of a nurse and social worker palliative telecare team on quality of life in outpatients with COPD, HF, or ILD compared with usual care.

Design, Setting, and Participants

Single-blind, 2-group, multisite randomized clinical trial with accrual between October 27, 2016, and April 2, 2020, in 2 Veterans Administration health care systems (Colorado and Washington), and including community-based outpatient clinics. Outpatients with COPD, HF, or ILD at high risk of hospitalization or death who reported poor quality of life participated.

Intervention

The intervention involved 6 phone calls with a nurse to help with symptom management and 6 phone calls with a social worker to provide psychosocial care. The nurse and social worker met weekly with a study primary care and palliative care physician and as needed, a pulmonologist, and cardiologist. Usual care included an educational handout developed for the study that outlined self-care for COPD, ILD, or HF. Patients in both groups received care at the discretion of their clinicians, which could include care from nurses and social workers, and specialists in cardiology, pulmonology, palliative care, and mental health.

Main Outcomes and Measures

The primary outcome was difference in change in quality of life from baseline to 6 months between the intervention and usual care groups (FACT-G score range, 0-100, with higher scores indicating better quality of life, clinically meaningful change ≥4 points). Secondary quality-of-life outcomes at 6 months included disease-specific health status (Clinical COPD Questionnaire; Kansas City Cardiomyopathy Questionnaire-12), depression (Patient Health Questionnaire-8) and anxiety (Generalized Anxiety Disorder-7) symptoms.

Results

Among 306 randomized patients (mean [SD] age, 68.9 [7.7] years; 276 male [90.2%], 30 female [9.8%]; 245 White [80.1%]), 177 (57.8%) had COPD, 67 (21.9%) HF, 49 (16%) both COPD and HF, and 13 (4.2%) ILD. Baseline FACT-G scores were similar (intervention, 52.9; usual care, 52.7). FACT-G completion was 76% (intervention, 117 of 154; usual care, 116 of 152) at 6 months for both groups. Mean (SD) length of intervention was 115.1 (33.4) days and included a mean of 10.4 (3.3) intervention calls per patient. In the intervention group, 112 of 154 (73%) patients received the intervention as randomized. At 6 months, mean FACT-G score improved 6.0 points in the intervention group and 1.4 points in the usual care group (difference, 4.6 points [95% CI, 1.8-7.4]; P = .001; standardized mean difference, 0.41). The intervention also improved COPD health status (standardized mean difference, 0.44; P = .04), HF health status (standardized mean difference, 0.41; P = .01), depression (standardized mean difference, -0.50; P < .001), and anxiety (standardized mean difference, -0.51; P < .001) at 6 months.

Conclusions and Relevance

For adults with COPD, HF, or ILD who were at high risk of death and had poor quality of life, a nurse and social worker palliative telecare team produced clinically meaningful improvements in quality of life at 6 months compared with usual care.

Trial Registration

ClinicalTrials.gov Identifier: NCT02713347.

A Typology for the Application of Team Coordination Dynamics Across Increasing Levels of Dynamic Complexity

OBJECTIVE

This review and synthesis examines approaches for measuring and assessing team coordination dynamics (TCD). The authors advance a system typology for classifying TCD approaches and their applications for increasing levels of dynamic complexity.

BACKGROUND

There is an increasing focus on how teams adapt their coordination in response to changing and uncertain operational conditions. Understanding coordination is significant because poor coordination is associated with maladaptive responses, whereas adaptive coordination is associated with effective responses. This issue has been met with TCD approaches that handle increasing complexity in the types of TCD teams exhibit.

METHOD

A three-level system typology of TCD approaches for increasing dynamic complexity is provided, with examples of research at each level. For System I TCD, team states converge toward a stable, fixed-point attractor. For System II TCD, team states are periodic, which can appear complex, yet are regular and relatively stable. In System III TCD, teams can exhibit periodic patterns, but those patterns change continuously to maintain effectiveness.

RESULTS

System I and System II are applicable to TCD with known or discoverable behavioral attractors that are stationary across mid-to long-range timescales. System III TCD is the most generalizable to dynamic environments with high requirements for adaptive coordination across a range of timescales.

CONCLUSION

We outline current challenges for TCD and next steps in this burgeoning field of research.

APPLICATION

System III approaches are becoming widespread, as they are generalizable to time- and/or scale-varying TCD and multimodal analyses. Recommendations for deploying TCD in team settings are provided.

Evidence-Based Pearls: How the Healthy Work Environment Effects Multidisciplinary Trauma Teams

Trauma remains a leading cause of death among adults. Care of the trauma patient requires highly skilled trauma teams. Trauma care begins in the field, then presents to the emergency room, proceeds to intensive care in many cases, and finally reaches recovery and rehabilitation. For patients, it can be a long road. To be effective, multidisciplinary trauma teams must expertly drill and practice skills, communicate among team members in closed loops, make split decisions affecting patient outcomes, and see the care through to the end. Many disruptions during the course of providing trauma care can alter safe outcomes for patients. The American Association of Critical Care Nurses Six Essentials of the Healthy Work Environment are presented as a framework to provide excellence in trauma care, both for the patient and team members. The six essentials of a healthy work environment include skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.

Beyond inclusion: Enacting team equity in precision medicine research

PURPOSE

To identify meanings of and challenges to enacting equitable diversification of genomics research, and specifically precision medicine research (PMR), teams.

METHODS

We conducted in-depth interviews with 102 individuals involved in three U.S.-based precision medicine research consortia and conducted over 400 observation hours of their working group meetings, consortium-wide meetings, and conference presentations. We also reviewed published reports on genomic workforce diversity (WFD), particularly those relevant to the PMR community.

RESULTS

Our study finds that many PMR teams encounter challenges as they strive to achieve equitable diversification on scientific teams. Interviewees articulated that underrepresented team members were often hired to increase the study's capacity to recruit diverse research participants, but are limited to on-the-ground staff positions with little influence over study design. We find existing hierarchies and power structures in the academic research ecosystem compound challenges for equitable diversification.

CONCLUSION

Our results suggest that meaningful diversification of PMR teams will only be possible when team equity is prioritized as a core value in academic research communities.

Preparing for patients with high-consequence infectious diseases: Example of a high-level isolation unit

Introduction

Patients with high-consequence infectious diseases (HCID) are rare in Western Europe. However, high-level isolation units (HLIU) must always be prepared for patient admission. Case fatality rates of HCID can be reduced by providing optimal intensive care management. We here describe a single centre’s preparation, its embedding in the national context and the challenges we faced during the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic.

Methods

Ten team leaders organize monthly whole day trainings for a team of doctors and nurses from the HLIU focusing on intensive care medicine. Impact and relevance of training are assessed by a questionnaire and a perception survey, respectively. Furthermore, yearly exercises with several partner institutions are performed to cover different real-life scenarios. Exercises are evaluated by internal and external observers. Both training sessions and exercises are accompanied by intense feedback.

Results

From May 2017 monthly training sessions were held with a two-month and a seven-month break due to the first and second wave of the SARS-CoV-2 pandemic, respectively. Agreement with the statements of the questionnaire was higher after training compared to before training indicating a positive effect of training sessions on competence. Participants rated joint trainings for nurses and doctors at regular intervals as important. Numerous issues with potential for improvement were identified during post processing of exercises. Action plans for their improvement were drafted and as of now mostly implemented. The network of the permanent working group of competence and treatment centres for HCID (Ständiger Arbeitskreis der Kompetenz- und Behandlungszentren für Krankheiten durch hochpathogene Erreger (STAKOB)) at the Robert Koch-Institute (RKI) was strengthened throughout the SARS-CoV-2 pandemic.

Discussion

Adequate preparation for the admission of patients with HCID is challenging. We show that joint regular trainings of doctors and nurses are appreciated and that training sessions may improve perceived skills. We also show that real-life scenario exercises may reveal additional deficits, which cannot be easily disclosed in training sessions. Although the SARS-CoV-2 pandemic interfered with our activities the enhanced cooperation among German HLIU during the pandemic ensured constant readiness for the admission of HCID patients to our or to collaborating HLIU. This is a single centre’s experience, which may not be generalized to other centres. However, we believe that our work may address aspects that should be considered when preparing a unit for the admission of patients with HCID. These may then be adapted to the local situations.

Exploring non-physician care professionals' roles in cancer multidisciplinary team meetings: A qualitative study

The growing complexity of cancer care necessitates collaboration among different professionals. This interprofessional collaboration improves cancer care delivery and outcomes. Treatment decision-making within the context of a multidisciplinaire team meeting (MDTMs) may be seen as a particular form of interprofessional collaboration. Various studies on cancer MDTMs highlight a pattern of suboptimal information sharing between attendants. To overcome the lack of non-medical, patient-based information, it might be recommended that non-physician care professionals play a key patient advocacy role within cancer MDTMs. This study aims to explore non-physician care professionals' current and aspired role within cancer MDTMs. Additionally, the perceived hindering factors for these non-physician care professionals to fulfil their specific role are identified. The analysis focuses on nurses, specialist nurses, head nurses, psychologists, social workers, a head of social workers and data managers. The results show that non-physician care professionals play a limited role during case discussions in MDTMs. Neither do they actively participate in the decision-making process. Barriers perceived by non-physician care professionals are classified on two main levels: 1) team-related barriers (factors internally related to the team) and 2) external barriers (factors related to healthcare management and policy). A group of non-physician care professionals also belief that their information does not add value in the decision-making proces and as such, they underestimate their own role in MDTMs. To conclude, a change of culture is needed towards an interdisciplinary collaboration in which knowledge and expertise of different professions are equally assimilated into an integrated perspective to guarantee a true patient-centred approach for cancer MDTMs.

A surgical needs assessment for airway rapid responses: A retrospective observational study

BACKGROUND

Airway rapid response (ARR) teams can be compiled of anesthesiologists, intensivists, otolaryngologists, general and thoracic surgeons, respiratory therapists, and nurses. The optimal composition of an ARR team is unknown but considered to be resource intensive. We sought to determine the type of technical procedures performed during an ARR activation to inform team composition.

METHODS

A large urban quaternary academic medical center retrospective review (2016-2019) of adult ARR patients was performed. Analysis included ARR demographics, patient characteristics, characteristics of preexisting tracheostomies, incidence of concomitant conditions, and procedures completed during an ARR event.

RESULTS

A total of 345 ARR patients with a median age of 60 years (interquartile range, 47-69 years) and a median time to ARR conclusion of 28 minutes (interquartile range, 14-47 minutes) were included. About 41.7% of the ARR had a preexisting tracheostomy. Overall, there were 130 procedures completed that can be performed by a general surgeon in addition to the 122 difficult intubations. These procedures included recannulation of a tracheostomy, operative intervention, new emergent tracheostomy or cricothyroidotomy, thoracostomy tube placement, initiation of extracorporeal membrane oxygenation, and pericardiocentesis.

CONCLUSION

Highly technical procedures are common during an ARR, including procedures related to tracheostomies. Surgeons possess a comprehensive skill set that is unique and comprehensive with respect to airway emergencies. This distinctive skill set creates an important role within the ARR team to perform these urgent technical procedures.

LEVEL OF EVIDENCE

Epidemiologic/prognostic, level III.

Virtual Team Rounding: A Cross-Specialty Inpatient Care Staffing Program to Manage COVID-19 Surges

PROBLEM

The SARS-CoV-2 (COVID-19) pandemic presented numerous challenges to inpatient care, including overtaxed inpatient medicine services, surges in patient censuses, disrupted patient care and educational activities for trainees, underused providers in certain specialties, and personal protective equipment shortages and new requirements for physical distancing. In March 2020, as the COVID-19 surge began, an interdisciplinary group of administrators, providers, and trainees at Brigham and Women's Hospital created an inpatient virtual staffing model called the Virtual Team Rounding Program (VTRP).

APPROACH

The conceptual framework guiding VTRP development was rapid-cycle innovation. The VTRP was designed iteratively using feedback from residents, physician assistants, attendings, and administrators from March to June 2020. The VTRP trained and deployed a diverse set of providers across specialties as "virtual rounders" to support inpatient teams by joining and participating in rounds via videoconference and completing documentation tasks during and after rounds. The program was rapidly scaled up from March to June 2020.

OUTCOMES

In a survey of inpatient providers at the end of the pilot phase, 10/10 (100%) respondents reported they were getting either "a lot" or "a little" benefit from the VTRP and did not find the addition of the virtual rounder burdensome. During the scaling phase, the program grew to support 24 teams. In a survey at the end of the contraction phase, 117/187 (62.6%) inpatient providers who worked with a virtual rounder felt the rounder saved them time. VTRP leadership collaboratively and iteratively developed best practices for challenges encountered during implementation.

NEXT STEPS

Virtual rounding provides a valuable extension of inpatient teams to manage COVID-19 surges. Future work will quantitatively and qualitatively assess the impact of the VTRP on inpatient provider satisfaction and well-being, virtual rounders' experiences, and patient care outcomes.

Care Coordination: A Concept Analysis

ABSTRACT

Care coordination is both a well-known concept discussed in a wide range of multidisciplinary health care literature and a familiar nursing role in clinical practice; however, the definition of care coordination lacks role clarity across disciplines and within the nursing profession. Despite variations, defining factors of care coordination practice exist; however, role ambiguity limits the effective implementation of evidence-based care coordination in practice and policy. Following Walker and Avant's eight-step concept analysis method, we aim to further clarify care coordination as a concept and practice role and examine the value that nursing brings to its implementation.

Effects of the World Health Organization Safe Childbirth Checklist on Quality of Care and Birth Outcomes in Aceh, Indonesia: A Cluster-Randomized Clinical Trial

Importance

To address major causes of perinatal and maternal mortality, the World Health Organization developed the Safe Childbirth Checklist (SCC), which to our knowledge has been rigorously evaluated only in combination with high-intensity coaching.

Objective

To evaluate the effect of the SCC with medium-intensity coaching on health care workers' performance of essential birth practices.

Design, Setting, and Participants

This cluster randomized clinical trial without blinding included 32 hospitals and community health centers in the province of Aceh, Indonesia (a medium-resource setting) that met the criterion of providing at least basic emergency obstetric and newborn care. Baseline data were collected from August to October 2016, and outcomes were measured from March to April 2017. Data were analyzed from January 2020 to October 2021.

Interventions

After applying an optimization method, facilities were randomly assigned to the treatment or control group (16 facilities each). The SCC with 11 coaching visits was implemented during a 6-month period.

Main Outcomes and Measures

For the primary outcome, clinical observers documented whether 36 essential birth practices were applied at treatment and control facilities at 1 or more of 4 pause points during the birthing process (admission to the hospital, just before pushing or cesarean delivery, soon after birth, and before hospital discharge). Probability models for binary outcome measures were estimated using ordinary least-squares regressions, complemented by Firth logit and complier average causal effect estimations.

Results

Among the 32 facilities that participated in the trial, a significant increase of up to 41 percentage points was observed in the application of 5 of 36 essential birth practices in the 16 treatment facilities compared with the 16 control facilities, including communication of danger signs at admission (treatment: 136 of 155 births [88%]; control: 79 of 107 births [74%]), measurement of neonatal temperature (treatment: 9 of 31 births [29%]; control: 1 of 20 births [5%]), newborn feeding checks (treatment: 22 of 34 births [65%]; control: 5 of 21 births [24%]), and the rate of communication of danger signs to mothers and birth companions verbally (treatment: 30 of 36 births [83%]; control: 14 of 22 births [64%]) and in a written format (treatment: 3 of 24 births [13%]; control: 0 of 16 births [0%]).

Conclusions and Relevance

In this cluster randomized clinical trial, health facilities that implemented the SCC with medium-intensity coaching had an increased rate of application for 5 of 36 essential birth practices compared with the control facilities. Medium-intensity coaching may not be sufficient to increase uptake of the SCC to a satisfying extent, but it may be worthwhile to assess a redesigned coaching approach prompting long-term behavioral change and, therefore, effectiveness.

Trial Registration

isrctn.org Identifier: ISRCTN11041580.

COVID-19: Overview of rheumatology fellows

SARS-COV-2 infection has spread worldwide since it originated in December 2019, in Wuhan, China. The pandemic has largely demonstrated the resilience of the world's health systems and is the greatest health emergency since World War II. There is no single therapeutic approach to the treatment of COVID-19 and the associated immune disorder. The lack of randomised clinical trials (RCTs) has led different countries to tackle the disease based on case series, or from results of observational studies with off-label drugs.

We as rheumatologists in general, and specifically rheumatology fellows, have been on the front line of the pandemic, modifying our activities and altering our training itinerary. We have attended patients, we have learned about the management of the disease and from our previous experience with drugs for arthritis and giant cell arteritis, we have used these drugs to treat COVID-19.

Now Is Our Time to Act: Why Academic Medicine Must Embrace Community Collaboration as Its Fourth Mission

In his Leadership Plenary at the Association of American Medical Colleges (AAMC) annual meeting, "Learn Serve Lead 2020: The Virtual Experience," president and CEO David Skorton emphasized that the traditional tripartite mission of academic medicine-medical education, clinical care, and research-is no longer enough to achieve health justice for all. Today, collaborating with diverse communities deserves equal weight among academic medicine's missions. This means going beyond "delivering care" to establishing and expanding ongoing, two-way community dialogues that push the envelope of what is possible in service to what is needed. It means appreciating community assets and creating ongoing pathways for listening to and learning from the needs, lived experiences, perspectives, and wisdom of patients, families, and communities. It means working with community-based organizations in true partnership to identify and address needs, and jointly develop, test, and implement solutions. This requires bringing medical care and public/population health concepts together and addressing upstream fundamental causes of health inequities. The authors call on academic medical institutions to do more to build a strong network of collaborators across public and population health, government, community groups, and the private sector. We in academic medicine must hold ourselves accountable for weaving community collaborations consistently throughout research, medical education, and clinical care. The authors recognize the AAMC can do better to support its member institutions in doing so and discuss new initiatives that signify a shift in emphasis through the association's new strategic plan and AAMC Center for Health Justice. The authors believe every area of academic medicine could grow and better serve communities by listening and engaging more and bringing medical care, public health, and other sectors closer together.

Multidisciplinary aerodigestive program at a children's hospital: A protocol for a prospective observational study

BACKGROUND

Children with complex chronic multisystemic diseases frequently require care from multiple pediatric subspecialists. The aerodigestive program is a multidisciplinary program that diagnoses and treats pediatric patients with complex multi-systematic problems affecting airway, breathing, feeding, swallowing, or growth. The aim of this study is to present the protocol of the aerodigestive program of a children's hospital.

METHODS AND DESIGN

This study is a prospective study to evaluate and compare the overall improvement of patients' objective and subjective conditions before and after the AeroDigestive Team (ADT) program. Among children from 1 month to 18 years of age, patients with complex problems of the airway, breathing, feeding, swallowing, or growth meeting at least two parameters of the inclusion criteria were enrolled. The overall process included referral based on the inclusion criteria, enrollment of ADT program with informed consents, interview and questionnaire for assessing patients' medical condition, prescheduling appointment, multi-specialists' evaluation, monthly team meetings, wrap-up discussion with the patients and family, therapeutic intervention, and follow-up at 6 months with the assessment of outcome measures. The outcome was evaluated objectively and subjectively. The objective outcome measure was divided into surgical or medical intervention, assessment of changes in medical condition, and follow-up study. Both caregiver interviews and questionnaires using a scoring system were used as subjective outcome measures before and after the ADT program. Children were scheduled to be followed-up at 6 months after the interventions or ADT meeting.

DISCUSSION

The aerodigestive program is expected to provide comprehensive and multidisciplinary management of children with complex airway and digestive tract disorders.

Evaluating diabetes care quality improvement strategies used by clinical teams in five primary care practices in New Zealand

BACKGROUND

Diabetes care is often sub-optimal. Quality improvement (QI) initiatives are intended to improve care processes and thereby improve patient outcomes. There is a need to assess the degree of implementation of QI strategies, as a prerequisite to managing implementation.

AIMS

Our study aims to describe the level of implementation of six QI strategies for improving primary care of diabetes (self-management support, team changes, case management, patient education, electronic patient registers and patient reminders).

METHODS

A survey and focus groups were conducted between October 2018 and January 2019. We invited eleven general practices in South Auckland, New Zealand. We constructed a questionnaire assessing six QI initiatives, adapting questionnaire items from published instruments. A summary score was calculated by QI strategy and by practice.

RESULTS

Five practices participated. All were simultaneously implementing clinical team changes, patient education, electronic patient registers and patient reminders, but type and level of implementations varied between the practices. The scoring system discriminated between practices with respect to both individual strategies and the practice summary score. Practices engaged well with the assessment. Results were reported back to practices who confirmed that the scoring was plausible. The study describes key features and challenges during the implementation process.

CONCLUSIONS

It is important to measure implementation of QI strategies. In this study of five practices, the instrument developed, and the associated measurement processes, were acceptable to practices and the results appear discriminatory and plausible.

System and capability of public health response to nuclear or radiological emergencies in China

In order to respond to nuclear or radiological emergencies effectively and protect the physical and mental health of the public, the national-, provincial-, municipal- and county-level public health response systems for nuclear or radiological emergencies had been established in China by the end of twentieth century. The health administrative departments at all levels have established professional emergency response teams, continue to improve their own level of emergency response systems and operating mechanisms, enhance the capabilities of radiation injury treatment, radiation monitoring and protection through training and exercises and also pay attention to the logistical support for emergency response. In this article the organizations, management system and capabilities of public health response to nuclear or radiological emergencies in China are briefly introduced. We try to strengthen information exchange and cooperation with foreign counterparts in this field in the future, so as to jointly promote the development of preparedness and response for nuclear or radiological emergencies.

Aerodigestive Clinics as Emerging Pediatric Care Model: The First 100 Patients in Israel

BACKGROUND

Aerodigestive clinics are run by interdisciplinary medical and surgical teams, and provide complex care coordination and combined endoscopies.

OBJECTIVES

To describe the design and patient population of the first pediatric aerodigestive center in Israel.

METHODS

A retrospective single-center cohort study was conducted describing patients followed in the aerodigestive clinic of Schneider Children's Medical Center of Israel, a tertiary pediatric hospital, between its inception in January 2017 and June 2020.

RESULTS

During the study period, 100 patients were seen at the combined respiratory and digestive (NoAM) clinic, with a total of 271 visits. Median age at first assessment was 29.5 months (range 3-216). Fifty-six patients (56%) had esophageal atresia and tracheoesophageal fistula. Thirty-nine patients had an identified genetic disorder, 28 had a primary airway abnormality, 28 were oxygen dependent, and 21 were born premature. Fifty-two patients underwent triple endoscopy, consisting of flexible bronchoscopy, rigid bronchoscopy, and gastroscopy. In 33 patients, esophageal dilatation was necessary. Six patients underwent posterior tracheopexy at a median of 6 months of age (range 5 days to 8 years) all with ensuing symptom improvement. The total mean parental satisfaction score on a Likert-type scale of 1-5 (5 = highest satisfaction) was 4.5.

CONCLUSIONS

A coordinated approach is required to provide effective care to the growing population of children with aerodigestive disorders. The cross fertilization between multiple disciplines offers a unique opportunity to develop high quality and innovative care. Outcome measures must be defined to objectively measure clinical benefit.

Advanced prehospital resuscitative care: Can we identify trauma patients who might benefit?

BACKGROUND

Uncontrolled truncal hemorrhage remains the most common cause of potentially preventable death after injury. The notion of earlier hemorrhage control and blood product resuscitation is therefore attractive. Some systems have successfully implemented prehospital advanced resuscitative care (ARC) teams. Early identification of patients is key and is reliant on rapid decision making and communication. The purpose of this simulation study was to explore the feasibility of early identification of patients who might benefit from ARC in a typical US setting.

METHODS

We conducted a prospective observational/simulation study at a level I trauma center and two associated emergency medical service (EMS) agencies over a 9-month period. The participating EMS agencies were asked to identify actual patients who might benefit from the activation of a hypothetical trauma center-based ARC team. This decision was then communicated in real time to the study team.

RESULTS

Sixty-three patients were determined to require activation. The number of activations per month ranged from 2 to 15. The highest incidence of calls occurred between 4 pm to midnight. Of the 63 patients, 33 were transported to the trauma center. The most common presentation was with penetrating trauma. The median age was 27 years (interquartile range, 24-45 years), 75% were male, and the median Injury Severity Score was 11 (interquartile range, 7-20). Based on injury patterns, treatment received, and outcomes, it was determined that 6 (18%) of 33 patients might have benefited from ARC. Three of the patients died en-route to or soon after arrival at the trauma center.

CONCLUSION

The prehospital identification of patients who might benefit from ARC is possible but faces challenges. Identifying strategies to adapt existing processes may allow better utilization of the existing infrastructure and should be a focus of future efforts.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, level III.

Evaluating the impact of integrated behavioral health intervention: Evidence from Rhode Island

There has been a historic separation between systems that address behavioral health problems and the medical care system that addresses other health issues. Integration of the 2 has the potential to improve care.The aim of this study was to evaluate the impact of Integrated Behavioral Health program on health care utilization and costs.Claims data between 2015 and 2018 from Rhode Island's All Payers Claims Database representing 42,936 continuously enrolled unique patients.Retrospective study based on propensity score-matched difference-in-differences framework.Utilization (emergency department visits, office visits, and hospitalizations) and costs (total, inpatient, outpatient, professional, and pharmacy).Integrated Behavioral Health intervention in Rhode Island was associated with reduction in healthcare utilization. Emergency department visits reduced by 6.4 per 1000 people per month and office visits reduced by 29.8 per 1000 people per month, corresponding to a reduction of 7% and 6%, respectively. No statistically significant association was observed between the intervention and hospitalizations. The evidence was mixed for cost outcomes, with negative association recorded between the intervention and the likelihood of incurring non-zero cost but no significant association was observed between the intervention and the level of costs. This relationship held true for most of the cost measures considered.Integrated Behavioral Health intervention in Rhode Island was associated with significant reductions in emergency department visits and office visits, with no effects on hospitalizations. In terms of the cost outcomes, we found evidence that the intervention negatively affected the likelihood of incurring any non-zero costs but did not affect the level of costs.

Improvement in student-led debriefing analysis after simulation-based team training using a revised teamwork assessment tool

BACKGROUND

Team debriefing is an important teamwork development intervention for improving team outputs in healthcare. Debriefing is a key component of experiential team training teamwork development interventions such as simulation-based training. Improving the quality of debriefing of healthcare teams, therefore, has multiple benefits. We investigated whether the quality of student-led debriefing improved using a shortened guide.

METHODS

Senior medical students, nurse anesthesia students, and senior undergraduate nursing students participated in student operating room team training at a health sciences center in the southeastern United States. Student teams participated in a dual-scenario simulation-based training session with immediate after-action debriefings after each scenario. In 2018, student teams conducted the second debriefing using as a guide the teamwork assessment scale, an 11-item, 3-subscale, 6-point Likert-type instrument. In 2019, they used a shortened, revised, 5-item version of the teamwork assessment scale, the quick teamwork assessment scale. Trained observers rated the quality of the student-led debriefings using the Objective Structured Assessment of Debriefing, an 8-item, 5-point instrument. The Wilcoxon-Mann-Whitney test was used to compare the teamwork assessment scale-guided and the quick teamwork assessment scale-guided mean item debriefing scores.

RESULTS

Two observers rated 3 student-led team debriefings using the teamwork assessment scales as a guide in 2018, and 6 such debriefings happened using the quick teamwork assessment scale as a guide in 2019. For each debriefing, observer scores were averaged for each Objective Structured Assessment of Debriefing item; these mean scores were then averaged with other mean scores for each year. The use of the quick teamwork assessment scale resulted in a statistically significant higher mean score for the Analysis Objective Structured Assessment of Debriefing item compared with the use of the teamwork assessment scale (4.92 [standard deviation 0.20] versus 3.83 [standard deviation 0.76], P = .023).

CONCLUSION

The use of a shortened teamwork assessment instrument as a debriefing guide for student teams in student operating room team training was more effective in analysis of actions than the original, longer tool. Next steps include determining the efficacy of the quick teamwork assessment scale in an actual clinical setting.

"In my age, we didn't have the computers": Using a complexity lens to understand uptake of diabetes eHealth innovations into primary care-A qualitative study

BACKGROUND

Shared decision-making is a central component of person-centred care and can be facilitated with the use of patient decision aids (PtDA). Barriers and facilitators to shared decision-making and PtDA use have been identified, yet integration of PtDAs into clinical care is limited. We sought to understand why, using the concepts of complexity science.

METHODS

We conducted 60-minute in-depth interviews with patients with diabetes, primary care physicians, nurses and dietitians who had participated in a randomized controlled trial examining the impact of MyDiabetesPlan (an online goal-setting PtDA). Relying on a qualitative description approach, we used a semi-structured interview guide to explore participants' experiences with using MyDiabetesPlan and how it was integrated into the clinical encounter and clinical care. Audiotapes were transcribed verbatim, then coded independently by two analysts.

FINDINGS

17 interviews were conducted (5 physicians, 3 nurses, 2 dietitians, 7 patients). Two themes were developed: (1) MyDiabetesPlan appeared to empower patients by providing tailored patient-important information which engaged them in decision-making and self-care. Patients' use of MyDiabetesPlan was however impacted by their competing medical conditions, other life priorities and socioeconomic context. (2) MyDiabetesPlan emphasized to clinicians a patient-centred approach that helped patients assume greater ownership for their care. Clinicians' use of MyDiabetesPlan was impacted by pre-existing clinical tools/workplans, workflow, technical issues, clinic administrative logistics and support, and time. How clinicians adapted to these barriers influenced the degree to which MyDiabetesPlan was integrated into care.

CONCLUSIONS

A complexity lens (that considers relationships between multiple components of a complex system) may yield additional insights to optimize integration of PtDA into clinical care. A complexity lens recognizes that shared decision-making does not occur in the vacuum of a clinical dyad (patient and clinician), and will enable us to develop a family of interventions that address the whole process, rather than individual components.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02379078.

Cardiac manifestations of the coronavirus disease-19: a review of pathogenesis, clinical manifestations, diagnosis, and treatment

The coronavirus disease-19 (COVID-19), first appearing in Wuhan, China, and later declared as a pandemic, has caused serious morbidity and mortality worldwide. Severe cases usually present with acute respiratory distress syndrome (ARDS), pneumonia, acute kidney injury (AKI), liver damage, or septic shock. However, with recent advances in severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) research, the virus´s effect on cardiac tissues has become evident. Reportedly, an increased number of COVID-19 patients manifested serious cardiac complications such as heart failure, increased troponin, and N-terminal pro-B-type natriuretic peptide levels (NT-proBNP), cardiomyopathies, and myocarditis. These cardiac complications initially present as chest tightness, chest pain, and heart palpitations. Diagnostic investigations such as telemetry, electrocardiogram (ECG), cardiac biomarkers (troponin, NT-proBNP), and inflammatory markers (D-dimer, fibrinogen, PT, PTT), must be performed according to the patient´s condition. The best available options for treatment are the provision of supportive care, anti-viral therapy, hemodynamic monitoring, IL-6 blockers, statins, thrombolytic, and anti-hypertensive drugs. Cardiovascular disease (CVD) healthcare workers should be well-informed about the evolving research regarding COVID-19 and approach as a multi-disciplinary team to devise effective strategies for challenging situations to reduce cardiac complications.

Telehealth strategy to mitigate the negative psychological impact of the COVID-19 pandemic on type 2 diabetes: A randomized controlled trial

AIMS

To assess the impact of teleintervention on mental health parameters in type 2 diabetes patients during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This is a controlled randomized trial for a multidisciplinary telehealth intervention in Southern Brazil, with social distancing measures. Adults aged 18 years or older with previous diagnosis of type 2 diabetes were included in the study. The intervention performed was a set of strategies to help patients stay healthy during the COVID-19 pandemic and included the maintaining of telephone contacts and providing educational materials on issues related to mental health, healthy habits, and diabetes care. The primary outcome was a positive screening for mental health disorders (Self-Reporting Questionnaire) after 16 weeks of intervention. A positive screening for mental health disorders was considered when the survey scored greater than or equal to 7. Secondary outcomes included a positive screening for diabetes-related emotional distress (Problem Areas in Diabetes), eating (Eating Attitudes Test), and sleep disorders (Mini Sleep Questionnaire). Comparisons with χ² tests for dichotomous outcomes, along with the Mann-Whitney U test, was used for between group analyses.

RESULTS

A total of 91 individuals agreed to participate (46 intervention group and 45 control group). There were no differences in demographic and clinical data at baseline. After 16 weeks of follow-up, a positive screening for mental health disorders was found in 37.0% of participants in the intervention group vs. 57.8% in the control group (P = 0.04). Diabetes-related emotional distress was found in 21.7% of participants in the intervention group vs. 42.2% in the control group (P = 0.03). No differences were found between groups with regard to eating and sleep disorders.

CONCLUSION

This study demonstrated that maintaining remote connections with health professionals during social distancing and quarantine have the potential to reduce the prevalence of positive screening for mental health disorders and diabetes-related emotional distress in adults with type 2 diabetes.

Reimagining the inpatient palliative care consult: lessons from COVID-19

As the number of inpatients with advanced age and chronic conditions rises, so too does the need for inpatient palliative care (PC). Despite the strong evidence base for PC, less than 50% of all inpatient PC needs are met by inpatient consults. Over the past several months in epicenters of the COVID-19 pandemic, PC providers have responded to the increased need for PC services through innovative digital programs including telepalliative care programs. In this article, we explore how PC innovations during COVID-19 could transform the PC consult to address workforce shortages and expand access to PC services during and beyond the pandemic. We propose a 3-pronged strategy of bolstering inpatient telepalliative care services, expanding electronic consults, and increasing training and educational tools for providers to help meet the increased need for PC services in the future.

Creating a pronation therapy team: One hospital's journey

ABSTRACT

Prone positioning is a recommended therapy for patients with COVID-19 who develop acute respiratory distress syndrome. This article describes the creation, operation, and evolution of the pronation therapy team at the author's Veterans Affairs facility.

Clinical Outcomes of Molecular Tumor Boards: A Systematic Review

We conducted this systematic review to evaluate the clinical outcomes associated with molecular tumor board (MTB) review in patients with cancer.

METHODS

A systematic search of PubMed was performed to identify studies reporting clinical outcomes in patients with cancer who were reviewed by an MTB. To be included, studies had to report clinical outcomes, including clinical benefit, response, progression-free survival, or overall survival. Two reviewers independently selected studies and assessed quality with the Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group or the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies depending on the type of study being reviewed.

RESULTS

Fourteen studies were included with a total of 3,328 patients with cancer. All studies included patients without standard-of-care treatment options and usually with multiple prior lines of therapy. In studies reporting response rates, patients receiving MTB-recommended therapy had overall response rates ranging from 0% to 67%. In the only trial powered on clinical outcome and including a control group, the group receiving MTB-recommended therapy had significantly improved rate of progression-free survival compared with those receiving conventional therapy.

CONCLUSION

Although data quality is limited by a lack of prospective randomized controlled trials, MTBs appear to improve clinical outcomes for patients with cancer. Future research should concentrate on prospective trials and standardization of approach and outcomes.

Development and implementation of a trauma team education program in Georgetown, Guyana

ABSTRACT

Trauma teams without structured team training demonstrate impaired team dynamics, which can cause delays in patient care, leading to poor patient outcomes. Improving team dynamics leads to better communication, reduced errors, and enhanced patient care. Evidence-based trauma team training was implemented and delivered within a resource-restricted ED.

Consensus disease definitions for neurologic immune-related adverse events of immune checkpoint inhibitors

Expanding the US Food and Drug Administration-approved indications for immune checkpoint inhibitors in patients with cancer has resulted in therapeutic success and immune-related adverse events (irAEs). Neurologic irAEs (irAE-Ns) have an incidence of 1%-12% and a high fatality rate relative to other irAEs. Lack of standardized disease definitions and accurate phenotyping leads to syndrome misclassification and impedes development of evidence-based treatments and translational research. The objective of this study was to develop consensus guidance for an approach to irAE-Ns including disease definitions and severity grading. A working group of four neurologists drafted irAE-N consensus guidance and definitions, which were reviewed by the multidisciplinary Neuro irAE Disease Definition Panel including oncologists and irAE experts. A modified Delphi consensus process was used, with two rounds of anonymous ratings by panelists and two meetings to discuss areas of controversy. Panelists rated content for usability, appropriateness and accuracy on 9-point scales in electronic surveys and provided free text comments. Aggregated survey responses were incorporated into revised definitions. Consensus was based on numeric ratings using the RAND/University of California Los Angeles (UCLA) Appropriateness Method with prespecified definitions. 27 panelists from 15 academic medical centers voted on a total of 53 rating scales (6 general guidance, 24 central and 18 peripheral nervous system disease definition components, 3 severity criteria and 2 clinical trial adjudication statements); of these, 77% (41/53) received first round consensus. After revisions, all items received second round consensus. Consensus definitions were achieved for seven core disorders: irMeningitis, irEncephalitis, irDemyelinating disease, irVasculitis, irNeuropathy, irNeuromuscular junction disorders and irMyopathy. For each disorder, six descriptors of diagnostic components are used: disease subtype, diagnostic certainty, severity, autoantibody association, exacerbation of pre-existing disease or de novo presentation, and presence or absence of concurrent irAE(s). These disease definitions standardize irAE-N classification. Diagnostic certainty is not always directly linked to certainty to treat as an irAE-N (ie, one might treat events in the probable or possible category). Given consensus on accuracy and usability from a representative panel group, we anticipate that the definitions will be used broadly across clinical and research settings.

Team working part 2: Team meetings

John Fowler, Educational Consultant, explores the pitfalls of meetings, and how to make the most of them.

Organizational determinants of information transfer in palliative care teams: A structural equation modeling approach

Several organizational factors facilitate or hinder information transfer in palliative care teams. According to past research, organizational factors that reduce information transfer include the inconsistent use of shared electronic patient files, frequent changes of healthcare staff, a lack of opportunities for personal exchange, and a lack of evaluation of collaborative processes. Insufficient information sharing between professionals can negatively impact patient safety, whereas studies have shown that some organizational factors improve collaboration between professionals and thus contribute to improved patient outcomes. The main purpose of this study is thus to investigate whether, and if so how, organizational factors contribute to successful information exchange in palliative care teams in Switzerland, while also accounting for the different care contexts of primary and specialized palliative care. A nationwide survey was aimed at medical professionals working in palliative care. In total, 379 participants (mean age = 49.8 years, SD = 10.3) were included in this study. Two main outcome variables were examined: healthcare providers' satisfaction with information transfer in their team and their overall satisfaction with communication in their team. Hypotheses were tested by employing structural equation modeling. Findings revealed that the strongest predictors for effective information transfer in palliative care teams were sufficient opportunities for face-to-face meetings and supervision alongside feedback tools to improve collaborative practices and the application of guidelines and standards for collaboration. Face-to-face meetings were an even greater contributor to information transfer in specialized settings, whereas sharing the same work-based values with colleagues was considered more important in primary settings. Results from this study contribute to the existing literature elucidating how information transfer is facilitated in the field of palliative care. If proposed measures are implemented, this could possibly improve patient outcomes in palliative care. Furthermore, the findings can be useful for healthcare organizations and associations to make more efficient resource allocation decisions with the aim to optimize information transfer within the workforce.

Practice Implications from the WCET® International Ostomy Guideline 2020

GENERAL PURPOSE

To introduce the 15 recommendations of the International Ostomy Guideline (IOG) 2020, covering the four key arenas of education, holistic aspects, and pre- and postoperative care; and to summarize key concepts for clinicians to customize for translation into their practice.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Analyze supporting evidence for the education recommendations in the IOG 2020.2. Identify a benefit of the International Charter of Ostomate Rights.3. Distinguish concepts related to pre- and postoperative ostomy-related care.4. Select a potential barrier to IOG 2020 guideline implementation.

Health service organisation impact on lower extremity amputations in people with type 2 diabetes with foot ulcers: systematic review and meta-analysis

AIMS

Despite the evidence available on the epidemiology of diabetic foot ulcers and associated complications, it is not clear how specific organizational aspects of health care systems can positively affect their clinical trajectory. We aim to evaluate the impact of organizational aspects of care on lower extremity amputation rates among people with type 2 diabetes affected by foot ulcers.

METHODS

We conducted a systematic review of the scientific literature published between 1999 and 2019, using the following key terms as search criteria: people with type 2 diabetes, diagnosed with diabetic foot ulcer, treated with specific processes and care pathways, and LEA as primary outcome. Overall results were reported as pooled odds ratios and 95% confidence intervals obtained using fixed and random effects models.

RESULTS

A total of 57 studies were found eligible, highlighting the following arrangements: dedicated teams, care pathways and protocols, multidisciplinary teams, and combined interventions. Among them, seven studies qualified for a meta-analysis. According to the random effects model, interventions including any of the four arrangements were associated with a 29% reduced risk of any type of lower extremity amputation (OR = 0.71; 95% CI 0.52-0.96). The effect was larger when focusing on major LEAs alone, leading to a 48% risk reduction (OR = 0.52; 95% CI 0.30-0.91).

CONCLUSIONS

Specific organizational arrangements including multidisciplinary teams and care pathways can prevent half of the amputations in people with diabetes and foot ulcers. Further studies using standardized criteria are needed to investigate the cost-effectiveness to facilitate wider implementation of improved organizational arrangements. Similarly, research should identify specific roadblocks to translating evidence into action. These may be structures and processes at the health system level, e.g. availability of professionals with the right skillset, reimbursement mechanisms, and clear organizational intervention implementation guidelines.

Implementing a Multidisciplinary Prone Positioning Team

ABSTRACT

The coronavirus disease 2019 pandemic has escalated clinical needs while interrupting regular processes and straining resources. Striving to deliver optimal care to infected patients with respiratory failure, Rush University Medical Center in Chicago created a multidisciplinary team to provide manual prone positioning safely and efficiently. Team members' experiences, which they shared through a survey, help to illustrate the advantages of a multidisciplinary approach and suggest opportunities to enhance the effectiveness of such a team.

International cooperation group of emergency surgery during the COVID-19 pandemic

PURPOSE

The COVID-19 pandemic has changed working conditions for emergency surgical teams around the world. International surgical societies have issued clinical recommendations to optimize surgical management. This international study aimed to assess the degree of emergency surgical teams' adoption of recommendations during the pandemic.

METHODS

Emergency surgical team members from over 30 countries were invited to answer an anonymous, prospective, online survey to assess team organization, PPE-related aspects, OR preparations, anesthesiologic considerations, and surgical management for emergency surgery during the pandemic.

RESULTS

One-hundred-and-thirty-four questionnaires were returned (N = 134) from 26 countries, of which 88% were surgeons, 7% surgical trainees, 4% anesthetists. 81% of the respondents got involved with COVID-19 crisis management. Social media were used by 91% of the respondents to access the recommendations, and 66% used videoconference tools for team communication. 51% had not received PPE training before the pandemic, 73% reported equipment shortage, and 55% informed about re-use of N95/FPP2/3 respirators. Dedicated COVID operating areas were cited by 77% of the respondents, 44% had performed emergency surgical procedures on COVID-19 patients, and over half (52%), favored performing laparoscopic over open surgical procedures.

CONCLUSION

Surgical team members have responded with leadership to the COVID-19 pandemic, with crisis management principles. Social media and videoconference have been used by the vast majority to access guidelines or to communicate during social distancing. The level of adoption of current recommendations is high for organizational aspects and surgical management, but not so for PPE training and availability, and anesthesiologic considerations.

The role of multidisciplinary team and molecular tumor board in the treatment of a patient with lung cancer

Nowadays, selection of appropriate therapy in patients with lung cancer is based on comprehensive molecular characteristics of their tumors. On molecular level, lung cancer is one of the best described solid tumors. Currently, there are already methods in routine clinical practice that enable a relatively quick, accurate and cost-effective analysis of dozens of genes and thus make it possible to determine a complex molecular characteristic of a tumor. This creates new possibilities to tailor the treatment to the patients to achieve long-term survival with a good quality of life. New technologies bring more and more information and to transform it into the best clinical benefit for the patient can be challenging. This is a place for the multidisciplinary approach in the form of a molecular tumor board. Its role is to try to indicate appropriate therapy based on the identified genetic alteration. Today, dozens of targeted drugs are available and new treatment options are emerging even for genetic alterations, which until now seemed to be undruggable.

Professional Development of Interprofessional Evidence-Based Practice Education

Health care professionals must be adept at conducting and using evidence-based practice (EBP). No best method to teach EBP to health care providers exists. This article outlines the steps and key points found to be important when developing and teaching EBP to interprofessional executive health care teams. [J Contin Educ Nurs. 2021;52(5):214-216.].

The Vanguard Study: Human Performance Evaluation of UK National Organ Retrieval Service Teams Utilizing a Single Scrub Practitioner in Multiorgan Retrieval

BACKGROUND

The National Organ Retrieval Service (NORS) 2015 review recommended a single scrub practitioner provide support simultaneously to abdominal and cardiothoracic teams in UK multiorgan retrieval. Previously, this model had been used only by the combined abdominal and cardiac team in Scotland. This study reports the impact on performance as part of the Vanguard project, which utilized the single scrub practitioner role with 5 NORS teams, to determine applicability United Kingdom wide.

METHODS

Participants comprised members of abdominal (n = 56) and cardiothoracic (n = 54) teams attending UK thoraco-abdominal retrievals. Data were collected by validated psychometric scales to assess individual workload, anxiety, confidence, demands/coping resources, and teamwork. Additional data were collected through open comments and quantitative data describing context and outcome of retrieval.

RESULTS

Abdominal and cardiothoracic teams showed different responses when using single (Vanguard) or dual scrub practitioners (Standard). Vanguard configuration was associated with significantly higher anxiety for abdominal but not cardiothoracic teams. Perceived workload increased for abdominal teams during Vanguard but decreased for cardiothoracic teams. Scrub practitioners reported elevated anxiety and decreased confidence in retrievals using Vanguard configuration.

CONCLUSIONS

This is the first large study examining human performance during organ retrieval in the United Kingdom. Despite previous regional success, this study showed a significant negative impact of the single scrub practitioner when extrapolated widely to UK teams. As a result of this study, NORS declined to implement the single scrub model. These data support the use of human performance analysis as an essential part of successful development in organ retrieval practice.

Barriers and enablers to effective interprofessional teamwork in the operating room: A qualitative study using the Theoretical Domains Framework

Background

Effective teamwork is critical for safe, high-quality care in the operating room (OR); however, teamwork interventions have not consistently resulted in the expected gains for patient safety or surgical culture. In order to optimize OR teamwork in a targeted and evidence-based manner, it is first necessary to conduct a comprehensive, theory-informed assessment of barriers and enablers from an interprofessional perspective.

Methods

This qualitative study was informed by the Theoretical Domains Framework (TDF). Volunteer, purposive and snowball sampling were conducted primarily across four sites in Ontario, Canada and continued until saturation was reached. Interviews were recorded, transcribed, and de-identified. Directed content analysis was conducted in duplicate using the TDF as the initial coding framework. Codes were then refined whereby similar codes were grouped into larger categories of meaning within each TDF domain, resulting in a list of domain-specific barriers and enablers.

Results

A total of 66 OR healthcare professionals participated in the study (19 Registered Nurses, two Registered Practical Nurses, 17 anaesthesiologists, 26 surgeons, two perfusionists). The most frequently identified teamwork enablers included people management, shared definition of teamwork, communication strategies, positive emotions, familiarity with team members, and alignment of teamwork with professional role. The most frequently identified teamwork barriers included others’ personalities, gender, hierarchies, resource issues, lack of knowledge of best practices for teamwork, negative emotions, conflicting norms and perceptions across professions, being unfamiliar with team members, and on-call/night shifts.

Conclusions

We identified key factors influencing OR teamwork from an interprofessional perspective using a theoretically informed and systematic approach. Our findings reveal important targets for future interventions and may ultimately increase their effectiveness. Specifically, achieving optimal teamwork in the OR may require a multi-level intervention that addresses individual, team and systems-level factors with particular attention to complex social and professional hierarchies.