Complex Medical Interventions Research Articles

Long-term Radiation Signal Persistence in Urine and Blood: A Two-year Analysis in Non-human Primates Exposed to a 4 Gy Total-Body Gamma-Radiation Dose.

National security concerns regarding radiological incidents, accidental or intentional in nature, have increased substantially over the past few years. A primary area of intense planning is the assessment of exposed individuals and timely medical management. However, exposed individuals who receive survivable radiation doses may develop delayed effects of acute radiation exposure many months or years later. Therefore, it is necessary to identify such individuals and determine whether their symptoms may have been initiated by radiation and require complex medical interventions. We previously developed early response metabolomic biosignatures in biofluids from non-human primates exposed to a total body gamma radiation dose of 4 Gy (up to 60 days). A follow-up of these animals has been ongoing with samples consistently collected every few months for up to 2 years after exposure, providing a unique cohort to determine if a radiation signal persists longer than 2 months. Metabolic fingerprinting in urine and serum determined that exposed animals remain metabolically different from pre-exposure levels and from age-matched controls, and the pre-determined biosignature maintains high sensitivity and specificity. Significant perturbations in tricarboxylic acid intermediates, cofactors and nucleotide metabolism were noted, signifying energetic changes that could be attributed to or perpetuate altered mitochondrial dynamics. Importantly, these animals have begun developing diseases such as hypertension much earlier than their age-matched controls, further emphasizing that radiation exposure may lead to accelerated aging. This NHP cohort provides important information and highlights the potential of metabolomics in determining persistent changes and a radiation-specific signature that can be correlated to phenotype.

Position Paper of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) and the German Roentgen Society (DRG) on Structural and Professional Requirements in Interventional Oncology.

Interventional oncology (IO) employs various techniques to enable minimally invasive, image-guided treatment of tumor diseases with both curative and palliative goals. Additionally, it significantly contributes to managing tumor-related and perioperative complications, offering diverse supportive procedures for patients at all stages of their diseases. The execution of IO procedures places unique demands on the equipment, personnel, and structural organization of radiological clinics, necessitating specific expertise from interventional radiologists.This position paper aims to comprehensively outline the multifaceted aspects of IO and discuss the requisite criteria for hospitals, radiological clinics, and interventional radiologists (IRs). Furthermore, it underscores overarching considerations of quality assurance that clinics and professional societies should prioritize.The requirements for hospitals, radiological clinics, and IRs are varied and demand not only a high level of proficiency in performing IO procedures but also in-depth knowledge of the differential therapy for various tumor diseases. This expertise is essential for effectively serving as clinical partners in the interdisciplinary treatment of oncologic patients. Additionally, a thorough understanding and safe handling of ionizing radiation technologies, along with proficiency in radiation protection methods, which are fundamental aspects of radiological specialist training, is crucial for ensuring the safety of IO procedures for both patients and staff. The Deutsche Gesellschaft für Interventionelle Radiologie und minimal-invasive Therapie (DeGIR) and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) have long-established dedicated quality management programs, accrediting radiology clinics and certifying IRs. These initiatives aim to uphold the highest standards of care and meet the quality expectations set by politics in healthcare system, particularly in the realm of interventional radiology. · The various procedures in the field of interventional oncology (IO) are complex medical interventions that require not only the most advanced technical equipment but also adequate human resources, particularly specialized expertise in interventional radiology, diagnostic imaging, oncology, and radiation protection.. · This expertise is an integral part of the specialized medical training in radiology and is certified by professional societies such as the German Society for Interventional Radiology (DeGIR) and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).. · Professional societies like DeGIR, CIRSE, and the American Society of Interventional Radiology (SIR) establish the necessary quality assurance framework for comprehensive, high-quality IO therapy through quality assurance (QA) registries, standard operating procedure (SOP) documents, and participation in guideline development.. · Currently, radiology is the only discipline that provides physicians with the theoretical and practical knowledge, skills, and competencies required to perform the demanding procedures in the field of IO through specialized training programs and tailored certification processes.. · Isfort P, Sommer CM, Bruners P et al. Position Paper of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) and the German Roentgen Society (DRG) on Structural and Professional Requirements in Interventional Oncology. Fortschr Röntgenstr 2024; DOI 10.1055/a-2373-1013.

PRINCIPLES OF MEDICAL TRIAGE FOR PATIENTS IN UKRAINE AND ABROAD

The overloading of emergency services is an urgent public health problem that affects all countries of the world, and despite numerous efforts in this field, significant progress has not yet been achieved. Against the background of the military invasion of muscovites to the territory of Ukraine with constant air attacks on cities with a high population density, the load on the emergency medical service has increased many times, which requires the fastest possible improvement of its structure and work organization. The one of the important factors driving the increase patient admissions to emergency departments is often non-urgent calls or visits, that is, visits by patients with conditions that do not require urgent attention or complex medical interventions and can be safely treated by primary medical aid. The consequences of overloading the emergency medical service negatively affect patients and medical personnel. So, low medical care quality leads to mortality among the patients, the numerous of medical errors and financial costs, and there is "burnout" of medical staff. The key to success is the correct organization of medical triage. Some countries have their own system of medical triage, although it is not different fundamentally. In the triage process, there are three options for evaluating the decision on the urgency category of assistance: expected result, excessive level or undersorting. Resource overspending occurs when the assigned triage category has a higher level of urgency than necessary. This so-called medical re-sorting is a reassessment of the severity of an illness or injury. Despite the progressively increasing load on the emergency medical service in Ukraine against the background of the moscow invasion and the increase in its funding in recent years, only a quantitative indicators of its work have significantly increased without much improvement in the quality of care due to absent of the any changes in the organization of the work of the emergency service which is based on outdated Soviet management principles.

Development and Initial Evaluation of Web-Based Cognitive Behavioral Therapy for Insomnia in Rural Family Caregivers of People With Dementia (NiteCAPP): Mixed Methods Study.

Informal caregivers of people with dementia frequently experience chronic insomnia, contributing to stress and poor health outcomes. Rural caregivers are particularly vulnerable but have limited access to cognitive behavioral therapy for insomnia (CBT-I), a recommended frontline treatment for chronic insomnia. Web-based delivery promises to improve insomnia, particularly for rural caregivers who have limited access to traditional in-person treatments. Our team translated an efficacious 4-session standard CBT-I content protocol into digital format to create NiteCAPP. This study aimed to (1) adapt NiteCAPP for dementia caregivers to create NiteCAPP CARES, a tailored digital format with standard CBT-I content plus caregiver-focused modifications; (2) conduct usability testing and evaluate acceptability of NiteCAPP CARES' content and features; and (3) pilot-test the adapted intervention to evaluate feasibility and preliminary effects on sleep and related health outcomes. We followed Medical Research Council recommendations for evaluating complex medical interventions to explore user needs and adapt and validate content using a stepwise approach: (1) a rural dementia caregiver (n=5) and primary care provider (n=5) advisory panel gave feedback that was used to adapt NiteCAPP; (2) caregiver (n=5) and primary care provider (n=7) focus groups reviewed the newly adapted NiteCAPP CARES and provided feedback that guided further adaptations; and (3) NiteCAPP CARES was pilot-tested in caregivers (n=5) for feasibility and to establish preliminary effects. Self-report usability measures were collected following intervention. Before and after treatment, 14 daily electronic sleep diaries and questionnaires were collected to evaluate arousal, health, mood, burden, subjective cognition, and interpersonal processes. The stepped approach provided user and expert feedback on satisfaction, usefulness, and content, resulting in a new digital CBT-I tailored for rural dementia caregivers: NiteCAPP CARES. The advisory panel recommended streamlining content, eliminating jargon, and including caregiver-focused content. Focus groups gave NiteCAPP CARES high usefulness ratings (mean score 4.4, SD 0.79, scored from 1=least to 5=most favorable; score range 4.2-4.8). Multiple features were evaluated positively, including the intervention's comprehensive and engaging information, caregiver focus, good layout, easy-to-access intervention material, and easy-to-understand sleep graphs. Suggestions for improvement included the provision of day and night viewing options, collapsible text, font size options, tabbed access to videos, and a glossary of terms. Pilot-test users rated usefulness (mean score 4.3, SD 0.83; range 4.1-4.5) and satisfaction (mean score 8.4, SD 1.41, scored from 1=least to 10=most satisfied; range 7.4-9.0) highly. Preliminary effects on caregiver sleep, arousal, health, mood, burden, cognition, and interpersonal processes (all P<.05) were promising. Adaptations made to standard digital CBT-I created a feasible, tailored digital intervention for rural dementia caregivers. Important next steps include further examination of feasibility and efficacy in a randomized controlled trial with an active control condition, a multisite effectiveness trial, and eventual broad dissemination. ClinicalTrials.gov NCT04632628; https://clinicaltrials.gov/ct2/show/NCT04632628.

Supporting SURgery with GEriatric Co-Management and AI (SURGE-Ahead): A study protocol for the development of a digital geriatrician.

Geriatric co-management is known to improve treatment of older adults in various clinical settings, however, widespread application of the concept is limited due to restricted resources. Digitalization may offer options to overcome these shortages by providing structured, relevant information and decision support tools for medical professionals. We present the SURGE-Ahead project (Supporting SURgery with GEriatric co-management and Artificial Intelligence) addressing this challenge. A digital application with a dashboard-style user interface will be developed, displaying 1) evidence-based recommendations for geriatric co-management and 2) artificial intelligence-enhanced suggestions for continuity of care (COC) decisions. The development and implementation of the SURGE-Ahead application (SAA) will follow the Medical research council framework for complex medical interventions. In the development phase a minimum geriatric data set (MGDS) will be defined that combines parametrized information from the hospital information system with a concise assessment battery and sensor data. Two literature reviews will be conducted to create an evidence base for co-management and COC suggestions that will be used to display guideline-compliant recommendations. Principles of machine learning will be used for further data processing and COC proposals for the postoperative course. In an observational and AI-development study, data will be collected in three surgical departments of a University Hospital (trauma surgery, general and visceral surgery, urology) for AI-training, feasibility testing of the MGDS and identification of co-management needs. Usability will be tested in a workshop with potential users. During a subsequent project phase, the SAA will be tested and evaluated in clinical routine, allowing its further improvement through an iterative process. The outline offers insights into a novel and comprehensive project that combines geriatric co-management with digital support tools to improve inpatient surgical care and continuity of care of older adults. German clinical trials registry (Deutsches Register für klinische Studien, DRKS00030684), registered on 21st November 2022.

Designing a national pediatric critical care database: a Delphi consensus study.

We sought to describe the processes undertaken for the systematic selection and consensus determination of the common data elements for inclusion in a national pediatric critical care database in Canada. We conducted a multicentre Delphi consensus study of Canadian pediatric intensive care units (PICUs) participating in the creation of a national database. Participants were PICU health care professionals, allied health professionals, caregivers, and other stakeholders. A dedicated panel group created a baseline survey of data elements based on literature, current PICU databases, and expertise in the field. The survey was then used for a Delphi iterative consensus process over three rounds, conducted from March to June 2021. Of 86 invited participants, 68 (79%) engaged and agreed to participate as part of an expert panel. Panel participants were sent three rounds of the survey with response rates of 62 (91%), 61 (90%) and 55 (81%), respectively. After three rounds, 72 data elements were included from six domains, mostly reflecting clinical status and complex medical interventions received in the PICU. While race, gender, and home region were included by consensus, variables such as minority status, indigenous status, primary language, and ethnicity were not. We present the methodological framework used to select data elements by consensus for a national pediatric critical care database, with participation from a diverse stakeholder group of experts and caregivers from all PICUs in Canada. The selected core data elements will provide standardized and synthesized data for research, benchmarking, and quality improvement initiatives of critically ill children.

Parenting a child with a kidney transplant-A study of everyday life experiences.

Kidney transplantation in children shows excellent long-term outcomes. However, parents feel responsible for ensuring that their child adheres to complex medical interventions. The dual role - as both parent and medical caregiver - gives rise to fatigue, stress, and emotional pain. Parental and family functioning are critically important to a child's disease course, development and well-being. To explore the experiences and perspectives of mothers and fathers of children with a kidney transplant. An explorative study using a qualitative method. Twelve parents (seven mothers and five fathers) of seven children with a kidney transplant. A qualitative exploratory study taking a phenomenological-hermeneutic approach. Semi-structured individual interviews were conducted. The data were analysed using Ricoeur's theory of narrative and interpretation on three levels: naïve reading, structural analysis, and critical interpretation and discussion. Four themes were generated: Kidney transplantation as a turning point, the importance of a close collaboration with health care professionals, being the child's voice, and managing the dual role as a parent, and medical caregiver in everyday life. Child kidney transplantation led to a transformation in the child, on the physical, mental, and social levels; however, the child was still in need of special attention and support. Problems with the kidney graft functioning resulted in frustration and disappointment in parents. Teamwork between a child's parents became evident, in coping with the dual role as a parent and medical caregiver. Parents aimed to maintain a clear structure related to medication and disease-related treatment. A close and trustful relationship and collaboration with health care professionals were significant and included listening to the voice of the child.

Collaborative science to advance gene therapies in resource-limited parts of the world

In the context of dramatic advances in the field of cell and gene therapies that have recently led to the approval of curative interventions for a number of diseases,1 it is important that these gains be extended for the benefit of patients everywhere.2 The first wave of technologies have, by nature, been associated with highly complex medical interventions that limit access and widespread use in resource-limited settings. Now, by updating an assessment of emerging platforms and technologies, and by incorporating the firsthand perspectives of stakeholders from all parts of the world, the opportunity exists to organize from the outset around safe and effective delivery of gene therapies in global settings.

Using a Retrospective Secondary Data Analysis to Identify Risk Factors for Pulmonary Complications in Trauma Patients in Pietermaritzburg, South Africa

BackgroundThe trauma burden in South Africa is significant. The objective of this project was to investigate the incidence of posttrauma pulmonary complications (PPCs) and to identify patient, health risks, and hospital factors, which predispose trauma patients to develop PPCs hospital in Pietermaritzburg, South Africa. MethodsThe design was a retrospective secondary data analysis of patients who presented as a trauma admission via the health systems’ Hybrid Electronic Medical Registry. The final data set included 6382 trauma admissions. ResultsThe PPC rate was 9.4% for patients with a surgical intervention versus 1.9% for those without a surgical intervention. Of the total 289 PPCs reported, the most common included pneumonia or atelectasis (46.4%) and prolonged ventilation (36.0%). The risk of developing a PPC was statistically significantly (P < 0.0001) associated with surgical intervention and the number of surgeries. ConclusionsThe trauma burden in South Africa requires complex medical and surgical interventions. The incidence of PPCs is significantly associated with surgical intervention. With the increasing demand to harness data and improve patient care, the Hybrid Electronic Medical Registry proves to be a driver for quality improvement.

Information component of stability of wandering complex systems of responsible purpose

Complex systems (processes) of responsible purpose are becoming more common in the modern world. The responsibility for designing complex systems is due to, for example, circumstances such as dependence on the latest health or even the lives of large numbers of people, the environmental security of regions and high material costs. These include responsible industrial and energy facilities, elements of transport, communication and safety systems, computer systems and networks, equipment for complex medical interventions in the human body, educational institutions, etc. What unites these systems and makes them subjects of research is that their complexity requires the use of modern information technologies and the appropriate "embedded" computer system for obtaining and processing real-time reliable data on the state of the object. Existing embedded information systems, as a rule, should be trained in advance to detect deviations of the parameters of the state of the controlled object from the norm, as well as to calculate and perform (sometimes, with the help of the operator) actions to compensate for such deviations. But, unfortunately, there are other systems that get into a situation (crisis), when their "passport" parameters are subject to significant deviations, and the existing, "built-in" information support for such situations is not trained, and quickly help in overcoming the consequences online crisis is not capable. After all, the controllability of SS SS, the fight against crises that these processes encounter, is based on the available adequate and relatively fast (they must have time to destroy the pseudo-resistant damaged object) models and methods of making urgent anti-crisis decisions in management. The aim of the work is to increase the efficiency of crisis management processes of rapid development of complex multi-parameter organizational and technical systems through the development and implementation of new models and methods. environment or, at least, the preservation of targets in times of crisis. To achieve this goal, the paper analyzes complex systems of responsible purpose in terms of their resistance to damage and crises; classification (sorting) of complex systems of responsible purpose with wandering elements is executed; the general algorithm of the general parametric space accumulation process at management of difficult systems is constructed; the implementation is performed and the practical significance of the obtained results is evaluated.

Interventions to improve physical performances of older people with cancer before complex medico-surgical procedures: Protocol for an umbrella review of systematic reviews and meta-analyses.

Background:Current demographics lead increasing older cancer patients to undergo complex medico-surgical procedures, with substantial risk of decompensations and deconditioning. The Prehabilitation & Rehabilitation in Oncology: Adaptation to Disease and Accompaniment of Patients’ Trajectories (PROADAPT) project is currently being developed with the aim of improving care, through standardized care pathways guided by existing evidence and implementation programs. A working group will specifically focus on improvement of physical performances before such procedures. These interventions may have been developed in different contexts: before surgery in large, before carcinologic surgery or complex medical interventions (chemotherapy, radiotherapy), or in primary care for elderly patients to prevent sarcopenia and frailty. Post-surgical interventions are out of the scope of this review. The objective of this review is to summarize the level of evidence to support physical reconditioning interventions and identify areas where further work is required.Methods:This umbrella review will include moderate to high quality systematic reviews, meta-analysis, and pre-existing umbrella or meta-reviews. Two reviewers will independently search the following databases: PubMed/MedLine, Cochrane Library, Embase, and CINAHL. Research strategy will use diverse keywords used to refer to the concepts of “prehabilitation,” “preoperative exercise,” or “preoperative rehabilitation,” with prespecified inclusion and exclusion criteria and only systematic reviews selection. The distinct types of interventions presented using PRISMA guidelines and a narrative reporting of results. A focus will be made on outcomes such as physical performances, quality of life, autonomy in everyday activities, or number of hospital bed days.Ethics and dissemination:Ethical approval is not required for such an umbrella review. Our review will be submitted for publication in a peer-reviewed international journal using open access option if available. It will be complementary to reviews focused on hospital discharge of older people.PROSPERO registration number:CRD42020100110.

Analysis of the relationship between hospital characteristics and survival in ovarian cancer: A historical cohort.

The management of ovarian cancer requires complex surgical and medical interventions. Specialized care is associated with superior outcomes in early and advanced stages. This study aimed to estimate the effect of hospital characteristics on the overall survival of women with epithelial ovarian cancer. We established a cohort with data recorded by the Fundação Oncocentro de São Paulo cancer registry. We included 6111 women treated for ovarian cancer in the state of Sao Paulo from January 2000 to December 2018. From 76 hospitals analyzed, 7 were high volume (20 or more cases a year) and 69 low volume. Twenty-nine were teaching and 47 community hospitals. A 10-year survival was analyzed using the Kaplan-Meyer estimator and the Cox model. Fifty-two percent of the epithelial ovarian cancer patients were treated in high-volume hospitals. High-volume - (HR, 0.86; 95% CI, 0.8-0.92; P < .001) and teaching - (HR, 0.91; 95% CI, 0.85-0.99; P = .019) were hospital characteristics associated with low risk of death in 10 years. High-volume and teaching hospitals are associated with better overall survival in ovarian cancer. Our data suggest that both hospital characteristics are important indicators of good quality of care in ovarian cancer treatment.

Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care (The FACTS Study Phase II) After Surgical Abortion: User-Centered Design.

BackgroundHuman-centered design is a methodology that applies an iterative participatory process that engages the end-user for whom an innovation or intervention is designed for from start to end. There is general evidence to support the use of human-centered design for development of tools to affect health behavior, but specifically for family planning provision. This study is part two of a three-phase study that uses a user-centered design methodology which uses the findings from Phase I to design, develop, and test a digital health solution to support follow-up after an induced surgical abortion.ObjectiveThe objectives for this study were to: (1) develop a Web-based intervention based on preferences and experiences of women who underwent an abortion as measured in the formative phase of the Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care Study; (2) conduct usability testing of the intervention to determine user-friendliness and appropriateness of the intervention; and (3) finalize a beta version of the Web-based intervention for pilot testing.MethodsThe study design was based on the “development-evaluation-implementation” process from the Medical Research Council Framework for Complex Medical Interventions. This study is in Phase II of III and is based on user-centered design methodology. Phase I findings demonstrated that women engage with technology to assist in clinical care and they preferred a comprehensive website with email or text notifications to support follow-up care. In Phase II we collaborated with family planning experts and key stakeholders to synthesize evidence from Phase I. With them and a development partner we built a prototype. Usability testing was completed with 9 participants using a validated System Usability Scale. This was then used to refine the intervention for Phase III pilot study. This study was approved by the local Ethics board.ResultsWe developed a comprehensive Web-based tool called myPostCare.ca, which includes: Post-Procedure Care, Emotional Well-Being Tool, Contraception Explorer, Sexual Health, Book an Appointment, and Other Resources. Additionally, over the course of a month after the procedure, automatic email notifications were sent to women as a form of virtual follow-up support, directing them to myPostCare.ca resources. The Web-based tool was refined based on usability testing results.ConclusionsThis study demonstrated that user-centered design is a useful methodology to build programs and interventions that are women-centered, specifically for abortion care.

Executive Function Impairments in Adolescents With Obesity and Obstructive Sleep Apnea Syndrome.

Adolescents with obesity and obstructive sleep apnea syndrome (OSAS) are at high risk of poor physical and cognitive health consequences. The purpose of this study was to explore executive function (EF) in adolescents with obesity and OSAS, describe physical activity and sleep duration, and explore the relationships between EF and physical activity and sleep duration. Participants comprised 20 adolescents (ages 11-17 years) with obesity (body mass index [BMI] ≥ 95th percentile) and OSAS (apnea-hypopnea index [AHI] ≥ 1.5 events/hr) participated in this observational pilot study with a prospective 1-week measurement protocol. Outcome measures included EF by the Behavior Rating Inventory of Executive Function-2, physical activity by Previous Day Physical Activity Recall, and sleep by Consensus Sleep Diary and actigraphy. Adolescents with obesity and OSAS had significantly worse EF by self- and parent-report than the normative sample (p ≤ .003), 45% had impaired EF and up to 30% had clinically significant impairments. Participants spent approximately 14.3 hr/day in light-intensity activity, and 33% did not engage in moderate-to-vigorous-intensity activity for at least 60 min on any days of data collection. Adolescents had insufficient sleep duration, averaging 6.9 hr/night. No significant relationships were identified between physical activity or sleep duration and EF. Providers should have a heightened awareness for EF impairments in obese adolescents with OSAS and consider how EF deficits may affect uptake and adherence to complex lifestyle and/or medical interventions among these patients.

Pradhan Mantri Jan Arogya Yojana: A Paper Tiger

The current budgetary allocation of ₹20 billion under the Pradhan Mantri Jan Arogya Yojana (PMJAY) is grossly inadequate. Our paper estimates that in the current fiscal year, the scheme will require an allocation of at least ₹420.73 billion to be able to give any meaningful coverage to 0.1 billion targetted families. This paper argues that such an expensive tertiary sector- led medical care coverage model is not the correct approach to ensure Universal Health Care (UHC) in India. A majority of illnesses are treatable at the primary level and an unbalanced promotion of the tertiary sector while neglecting primary healthcare will cause a delay in treatments, resulting in more complex and expensive medical interventions. What India urgently needs is to develop a comprehensive primary healthcare system.

Predictors of Posttraumatic Growth Post Lung Transplant

The role of quality of life and post traumatic growth (PTG) in lung transplant recipients has not been previously studied. Many patients experience complex medical interventions that impact on quality of life through physical and psychological complications. Posttraumatic stress disorder can follow and interfere with quality of life. There has been growing evidence examining the existence of, and benefits from, posttraumatic growth which develops after a traumatic intervention and contributes to an increase in quality of life. The purpose of this study was to explore the relationships between cognitive processing, distress, social support, resilience and PTG following lung transplant.

Improved Outcomes With a Physical Therapy and Nursing Driven Progressive Upright Mobility Protocol

SESSION TITLE: Improving Outcomes in the ICU SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 02:45 PM - 04:15 PM PURPOSE: We identified an opportunity for improvement in minimizing patient sedation and maximizing mobility. The purpose of this project was to address both by focusing on improving mobility. METHODS: All Registered Nurses (RN) and Nurse’s Aides in the Intensive care unit were first educated by the ICU Clinical Nurse Specialists on the benefits of mobility on patient outcomes as well as the detrimental effects of immobility. This was done to provide the necessary context to improve nursing engagement with the importance of early mobility in the critically ill patient. Next all RNs were introduced to the “Progressive Upright Mobility Protocol”. This protocol was developed by the ICU team (physicians, nurses, physical and respiratory therapists) from the existing literature on patient mobility. The protocol was designed to be a standing order in the ICU. After 24 hours in the ICU, critically ill patients automatically had the mobility protocol implemented as part of their routine care. The protocol was designed to have an assessment and promotion of progressive mobility every 4 hours except for the hours of 11pm to 7am to facilitate sleep. Our ICU based Physical Therapist helped advise and direct mobility interventions. The bedside RN was expected to assess and document the activity level of patient. If the patient had not progressed from the previous assessment nurses were to provide documentation as to why progression was not achieved. Assessments were to continue until the patient attained the highest level of mobility. RESULTS: Mobility is measured on a 0 to 6 scale. Daily and monthly averages of all patients were calculated over a 7 month period. Daily averages were 2.8 at the study inception and 4.8 at the end (p<.001, Cox-Stuart test for trend). The monthly averages were 2.89, 3.01, 3.41, 3.67, 4.11, 3.48, and 4.4. Mobility was the highest at 1200hr and 1600hr. Most frequent barriers to mobility were contraindication due to open abdominal wounds and complex medical interventions (i.e. Extracorporeal membrane oxygenation, Continuous Renal Replacement Therapy) 27%; inability to follow commands 25%; hemodynamic or respiratory instability 12%. Sedation was a barrier in only 5% of patients. Patients on ventilators were not found to be a barrier. All patients were included in data analysis and scoring including those patients with contraindications to the protocol. CONCLUSIONS: With a dedicated Physical Therapist, engaged nurses and attention to detail, we were able to significantly improve the functional mobility of our ICU population. Overall sedation of our ventilated patients was decreased, creating a cultural shift with goals of the interdisciplinary team directed toward early activity. CLINICAL IMPLICATIONS: Using a multi-disciplinary approach, patient mobility and sedation can be optimized. More study will be required to assess any effect on ventilator days, length of stay or mortality DISCLOSURE: The following authors have nothing to disclose: Jessica Parry, Michael Allain, Russell Acevedo, David Landsberg, Daniel Polacek, Ryan Magnuson No Product/Research Disclosure Information

Confronting the paradigm of discipline specific expert knowledge: Is professional integration the Holy Grail for sustainable and authentic models of co-production and integrated care?

The World Health Organisation (WHO) global strategy on-people centred and integrated health services calls for a radical shift in the way health services are funded, managed and delivered. The juxtaposition of longevity, burden of chronic disease and availability of complex medical interventions is stretching the health system’s ability to deliver, and government’s capacity to financially sustain. Online availability of healthcare information has created a ‘participative consumer’ challenging the historical, paternalistic and imbalanced clinician-patient relationship. Transition from ‘informed patient-care’ to ‘patient informed care’ is driving a new model of co-produced health, where care is delivered in an equal and reciprocal relationship between the consumer and provider of care. Governments and health providers globally have recognised that sustainability of quality and cost-effective care requires them to move beyond rhetoric and adapt to a person-centred and integrated health care model that recognises the consumer and their family as lived-experts in the co-production of their health care. So, with this level of commitment, why is integration so difficult? Is inter-professional education and training the missing link? Is professional integration the Holy Grail for sustainable and authentic models of co-production and integrated care? Does the current traditional approach to undergraduate health professional training act as a barrier to consumer-centred care? Does the structure of intra-discipline specific knowledge create a professional “inwardness” and impervious professional boundary that does not adequately prepare the new graduate to embrace and work within co-produced and integrated models of care? This paper will present a new associate degree in aged and integrated care that has been designed to create an ‘unbounded-discipline-specific professional’ prepared specifically to work within a co-produced model of integrated service delivery. The curriculum will focus on imparting a comprehensive knowledge of the principles underpinning integrated health care within the context of ageing from primary through to tertiary care; an advanced understanding of the values, theory and application of person-centred care; and capacity to lead, manage and work within a model of co-designed service delivery

NGOs in Specialised Health Care: A Study of Cachar Cancer Hospital Society of Cachar District of Assam

Prevention of diseases, diagnosis, treatment of illness, injury in human beings, etc., forms the subject matter of health care. Diseases like diabetes, stroke, cancer, cardiac diseases, renal diseases and so on needs specialised health care services owing to their specific treatment modalities. The Government of India has been trying its best to deliver health care services at the primary, secondary and tertiary level. Tertiary health care services provide specialised and super-speciality health care services which includes cancer management, neurology and neurosurgery, cardiology and cardio-thoracic surgery, nephrology and urology, and a host of other complex medical and surgical interventions. But these specialised and super specialised health care services are often very costly and are beyond the affordability of general population. Moreover, the Government with its limited resources are not able to provide such services to all the needy people. So, the Government took initiative in including various NGOs in providing such type of specialised and super-speciality health care services so as to benefit the needy and the poor. The present paper discusses about such activities by NGOs in the field of specialised health care, citing the example of The Cachar Cancer Hospital Society (CCHS), a NGO which provides specialised health care services in the field of cancer, to the needy and the poor population.

WHO cares? Safety checklists in echocardiography.

The number of potentially preventable medical errors that occur has been steadily increasing. These are a significant cause of patient morbidity, can lead to life-threatening complications and may result in a significant financial burden on health care. Effective communication and team working reduce errors and serious incidents. In particular the implementation of the World Health Organisation (WHO) Safe Surgery Checklist has been shown to reduce in-hospital mortality, postoperative complications and the incidence of surgical site infection. However an increasing number of complex medical procedures and interventions are being performed outside of the theatre environment. The lessons learnt from the surgical setting are relevant to other procedures performed in other areas. For the echocardiographer, transoesophageal echocardiography (TOE) is one such procedure in which there is the potential for medical errors that may result in patient harm. This risk is increased if patient sedation is being administered. The British Society of Echocardiography and the Association of Cardiothoracic Anaesthetists have developed a procedure specific checklist to facilitate the use of checklists into routine practice. In this article we discuss the evolution of the WHO safety checklist and explore its relevance to TOE.