Dedicated Team Members Research Articles

MISSION IMPOSSIBLE? Integrated services for people with SMI and SUD - The importance of good leadership and management.

Introduction: Better services for people with mental illness and substance use disorder (SUD) can be looked at as a Mission Oriented Innovation (MOI). People with severe mental illness (SMI) and SUD are often in the need of a range of different services, and different service models for coordinating such services have been introduced through the years.
 Aim: This study explores what inhibits and promotes integrated services for people with SMI and SUD in the service model FACT – Flexible Assertive Community Treatment.
 Methods: This is a qualitative explorative multiple-case study with the use of focus group interviews and reflexive thematic analysis (RTA) of team members in three different FACT-teams in Norway.
 Results: In team A the themes ‘Poor and lacking communication’, ‘Culture & Attitude’ and ‘Some resources are missing’ inhibits integrated services. And ‘A holistic and open work environment’, ‘Systemic assertive’ and ‘Focus on social recovery’ promotes. In team B ‘Lack of resources’, ‘Incorrect focus or problem focused practice’ inhibits, and ‘Function recovery advocacy & practice – Function FACT’ and ‘Good triple Management’ promotes. In team C ‘Administration & Management matters’, ‘Segregation & Prioritizing’ and ‘External interaction’ inhibits, and ‘Skilled, creative & dedicated team members’, ‘The FACT service model’ and ‘Internal & external cooperation’ promotes.
 Conclusion: Will be presented at the conference.
 The study also has PPI - Personal and Public Involvement with the engagement of three peer co-researchers contributing to the research project INNOFACT from start to end. The next step is to summarize and conclude regarding the importance of good leadership and management that will be presented at the conference. Later on the peer co-researchers will interview the patients about the same research questions.
 There are to our knowledge no studies about what inhibits and promotes integrated services for people with dual (and multiple) diagnosis in the service model FACT. 

Percutaneous endoscopic gastrostomy in amyotrophic lateral sclerosis: outcomes of a dedicated anesthesia and surgery protocol.

Patients requiring percutaneous endoscopic gastrostomy (PEG) for amyotrophic lateral sclerosis (ALS) related dysphagia represent a clinical challenge. Diminished pulmonary function and aspiration risks can lead to anesthesia-related complications, and gastric displacement from hemidiaphragm elevation may preclude safe gastric access. This study reports the efficacy and outcomes of a dedicated anesthesia/surgery management protocol for ALS patients undergoing PEG. In 2013, a PEG placement protocol for ALS patients was developed emphasizing efficient pre-operative evaluation, rapidly metabolized anesthetic agents, and minimization of opioid use. Outcomes were analyzed retrospectively. Preoperative weight loss, pulmonary function tests, total analgesia, procedural time, and 90-day morbidity and mortality were recorded. From 2013-2019, 67 ALS patients (mean age 65.3years, 52.2% female) received a PEG under the protocol. Mean percentage weight loss 6months before PEG was 9.3 ± 5.1% with 38.8% of patients meeting criteria for severe malnutrition. Mean anesthesia time (propofol induction to anesthesia emergence) was 34.5 ± 10.8min and mean operative time (endoscope insertion to dressing placement) was 16.4 ± 8.2min. Regional anesthesia with liposomal bupivacaine was performed in 76.1%. All attempts at PEG placement were successful. With a mean follow-up of 6.1 ± 6.8months, all PEGs were functional and there were no surgical site complications. Thirty-day readmission rate was 7.0% and 90-day mortality was 22.4% (46.7% occurring within 30days). Mean time from surgery to death was 8.8 ± 7.8months. Protocols for optimizing PEG may help overcome challenges present in the ALS patient population. Despite patient comorbidities, protocol implementation and dedicated team members resulted in a high procedural success rate and low complication rate. Further study is warranted to optimize the timing of PEG placement in relation to ALS disease progression and determine the utility of regional anesthesia during PEG placement.

EarlyMYCO: A Pilot Mother-Child Cohort Study to Assess Early-Life Exposure to Mycotoxins-Challenges and Lessons Learned.

Early-life exposure occurs during gestation through transfer to the fetus and later, during lactation. Recent monitoring data revealed that the Portuguese population is exposed to mycotoxins, including young children. This study aimed to develop a pilot study to assess the early-life exposure to mycotoxins through a mother–child cohort, and to identify the associated challenges. Participants were recruited during pregnancy (1st trimester) and followed-up in three moments of observation: 2nd trimester of pregnancy (mother), and 1st and 6th month of the child’s life (mother and child), with the collection of biological samples and sociodemographic and food consumption data. The earlyMYCO pilot study enrolled 19 mother–child pairs. The analysis of biological samples from participants revealed the presence of 4 out of 15 and 5 out of 18 mycotoxins’ biomarkers of exposure in urine and breast milk samples, respectively. The main aspects identified as contributors for the successful development of the cohort were the multidisciplinary and dedicated team members in healthcare units, reduced burden of participation, and the availability of healthcare units for the implementation of the fieldwork. Challenges faced, lessons learned, and suggestions were discussed as a contribution for the development of further studies in this area.

Role of Hand Hygiene and Sterile Blood Sampling in Reduction of False Positive Blood Cultures from a Neonatal Intensive Care Unit of a Rural Teaching Hospital: A Quasi-experimental Study

Introduction: Blood culture remains the gold standard for diagnosis of newborn infections. Its contamination not only results in inadvertent use of antimicrobials against the false positives but also causes substantial financial burden and patient safety concerns. There are various ways to reduce blood contamination, of which hand hygiene and sterile blood sampling are most crucial. Aim: To evaluate and reduce the blood contamination rate and false positive blood cultures from the Neonatal Intensive Care Unit (NICU). Materials and Methods: The prevalent bacteriology and Blood Culture Contamination Rate (BCCR) at the NICU was assessed by a retrospective study on all the neonates with suspected sepsis who had blood culture at admission. Healthcare workers at NICU were observed for their hand wash and sterile blood sampling technique by dedicated team members. Identified deficiencies among them were intervened by an educational model with regular training and reinforcement on hygienic practices for three months. Postintervention prospective study was done on all the neonates with suspected sepsis who had blood culture at admission. During this period the same educational model continued, to know its efficacy in reduction of blood contamination and change of bacteriology pattern. Data collected was entered into Microsoft excel sheet 2010 version and analysed using software Stata 14.0 version. Results: Preintervention blood culture reports of 205 neonates screened for sepsis showed 58 (28.3%) samples with positive growth. Of this, 18 were contaminants, 31 were Coagulase Negative Staphylococci (CoNS), three gram negative and six gram positive organisms with blood contamination rate of 8.7%. Blood culture reports of postintervention study on 200 neonates screened for sepsis showed 41 (20.5%) samples positive for growth. Bacteriology showed 12 contaminants, 13 CoNS, eight gram positives, seven gram negatives and one fungal growth with BCCR of 6%. After intervention growth of CoNS was reduced which was statistically significant (p<0.05). Conclusion: Simple inexpensive education programme helps the healthcare workers to follow the standard technique of hand wash and sterile blood sampling which goes a long way in reducing blood culture contamination.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Managing COVID-19 in Surgical Systems.

Managing COVID-19 in Surgical Systems.

Evaluating the national multisite implementation of dialectical behaviour therapy in a community setting: a mixed methods approach

BackgroundThe implementation of evidence-based interventions for borderline personality disorder in community settings is important given that individuals with this diagnosis are often extensive users of both inpatient and outpatient mental health services. Although work in this area is limited, previous studies have identified facilitators and barriers to successful DBT implementation. This study seeks to expand on previous work by evaluating a coordinated implementation of DBT in community settings at a national level. The Consolidated Framework for Implementation Research (CFIR) (Damschroder et al., Implementation Sci. 4:50, 2009) provided structural guidance for this national level coordinated implementation.MethodsA mixed methods approach was utilised to explore the national multisite implementation of DBT from the perspective of team leaders and therapists who participated in the coordinated training and subsequent implementation of DBT. Qualitative interviews with DBT team leaders (n = 8) explored their experiences of implementing DBT in their local service and was analysed using content analysis. Quantitative surveys from DBT therapists (n = 74) examined their experience of multiple aspects of the implementation process including orienting the system, and preparations and support for implementation. Frequencies of responses were calculated. Written qualitative feedback was analysed using content analysis.ResultsFive themes were identified from the interview data: team formation, implementation preparation, client selection, service level challenges and team leader role. Participants identified team size and support for the team leader as key points for consideration in DBT implementation. Key challenges encountered were the lack of system support to facilitate phone coaching and a lack of allocated time to focus on DBT. Implementation facilitators included having dedicated team members and support from management.ConclusionsThe barriers and facilitators identified in this study are broadly similar to those reported in previous research. Barriers and facilitators were identified across several domains of the CFIR and are consistent with a recently published DBT implementation Framework (Toms et al., Borderline Personal Disord Emot Dysregul. 6: 2, 2019). Future research should pay particular attention to the domain of characteristics of individuals involved in DBT implementation. The results highlight the importance of a mandated service plan for the coordinated implementation of an evidence-based treatment in a public health service.Trial registrationClinicalTrials.gov ID: NCT03180541; Registered June 7th 2017 ‘retrospectively registered’.

Statewide quality improvement initiative to implement immediate postpartum long-acting reversible contraception

Women face barriers to obtaining contraception and postpartum care. In a review of Tennessee birth data from 2014, 56% of pregnancies were unintended, 22.7% were short-interval pregnancies, and 57.9% of women who were not intending to get pregnant were not using contraception. Offering long-acting reversible contraceptive methods in the immediate postpartum period allows women who desire these effective methods of contraception to obtain unobstructed access and lower unintended and short-interval pregnancy rates. We report the experience of Tennessee's perinatal quality collaborative that aimed to address unintended and short-interval pregnancy by increasing access to immediate postpartum long-acting reversible contraception through woman-centered counseling and ensuring reimbursement for devices. This followed a policy change in November 2017 that allowed women who were insured under Tennessee Medicaid programs (TennCare) to achieve access to immediate postpartum long-acting reversible contraception. From March 2018 to March 2019, 6 hospital sites participated in this statewide quality improvement project that was based on the Institute of Health Improvement Breakout Collaborative model. An evidence-based toolkit was created to provide guidance to the sites. During the year of implementation, monthly huddles occurred, and each facility took a differing amount of time to implement immediate postpartum long-acting reversible contraception. Various statewide and hospital-specific barriers occurred and were overcome throughout theyear. In total, 2012 long-acting reversible contraception devices were provided to eligible and desiring women. All but 1 institution was able to offer immediate postpartum long-acting reversible contraception by March 2019. Reimbursement was the biggest statewide barrier because rates were low initially but improved through intensive intervention by dedicated team members at each site and the state level. Even with dedicated team members, false assurances were given repeatedly by billing and claims staff. A statewide quality improvement project can increase access to immediate postpartum long-acting reversible contraception. Implementation and reimbursement require a dedicated team and coordination with all stakeholders. Verification of reimbursement with leaders at TennCare was essential for project sustainment and facilitated improved reimbursement rates. The impact on unintended and short-interval pregnancies requires long-term future investigation.

Assessment of Rapid Response Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest

Rapid response teams (RRTs) are foundational to hospital response to deteriorating conditions of patients. However, little is known about differences in RRT organization and function across top-performing and non-top-performing hospitals for in-hospital cardiac arrest (IHCA) care. To evaluate differences in design and implementation of RRTs at top-performing and non-top-performing sites for survival of IHCA, which is known to be associated with hospital performance on IHCA incidence. A qualitative analysis was performed of data from semistructured interviews of 158 hospital staff members (nurses, physicians, administrators, and staff) during site visits to 9 hospitals participating in the Get With The Guidelines-Resuscitation program and consistently ranked in the top, middle, and bottom quartiles for IHCA survival during 2012-2014. Site visits were conducted from April 19, 2016, to July 27, 2017. Data analysis was completed in January 2019. Semistructured in-depth interviews were performed and thematic analysis was conducted on strategies for IHCA prevention, including RRT roles and responsibilities. Of the 158 participants, 72 were nurses (45.6%), 27 physicians (17.1%), 27 clinical staff (17.1%), and 32 administrators (20.3%). Between 12 and 30 people at each hospital participated in interviews. Differences in RRTs at top-performing and non-top-performing sites were found in the following 4 domains: team design and composition, RRT engagement in surveillance of at-risk patients, empowerment of bedside nurses to activate the RRT, and collaboration with bedside nurses during and after a rapid response. At top-performing hospitals, RRTs were typically staffed with dedicated team members without competing clinical responsibilities, who provided expertise to bedside nurses in managing patients who were at risk for deterioration, and collaborated with nurses during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgment and experience without fear of reprisal from physicians or hospital staff. In contrast, RRT members at non-top-performing hospitals had competing clinical responsibilities and were generally less engaged with bedside nurses. Nurses at non-top-performing hospitals reported concerns about potential consequences from activating the RRT. This qualitative study's findings suggest that top-performing hospitals feature RRTs with dedicated staff without competing clinical responsibilities, that work collaboratively with bedside nurses, and that can be activated without fear of reprisal. These findings provide unique insights into RRTs at hospitals with better IHCA outcomes.

Trauma Providers' Perceptions of Frailty Assessment: A Mixed-Methods Analysis of Knowledge, Attitudes, and Beliefs.

Quality improvement in geriatric trauma depends on timely identification of frailty, yet little is known about providers' knowledge and beliefs about frailty assessment. This study sought to understand trauma providers' understanding, beliefs, and practices for frailty assessment. We developed a 20-question survey using the Health Belief Model of health behavior and surveyed physicians, advanced practice providers, and trainees on the trauma services at a single institution that does not use formal frailty screening of all injured seniors. Results were analyzed via mixed methods. One hundred fifty-one providers completed the survey (response rate 92%). Respondents commonly included calendar age as an integral factor in their determinations of frailty but also included a variety of other factors, highlighting limited definitional consensus. Respondents perceived frailty as important to older adult patient outcomes, but assessment techniques were varied because only 24/151 respondents (16%) were familiar with current formal frailty assessment tools. Perceived barriers to performing a formal frailty screening on all injured older adults included the burdensome nature of assessment tools, insufficient training, and lack of time. When prompted for solutions, 20% of respondents recommended automation of the screening process by trained, dedicated team members. Providers seem to recognize the impact that a diagnosis of frailty has on outcomes, but most lack a working knowledge of how to assess for frailty syndrome. Some providers recommended screening by designated, formally trained personnel who could notify decision makers of a positive screen result.

More Than 300 Consecutive Living Donor Liver Transplants a Year at a Single Center

BackgroundLiving donor liver transplantation (LDLT) has been the first option for the patients requiring liver transplantation in East Asia because of the scarcity of cadaveric grafts. We have performed consecutively more than 300 LDLTs per year, and herein report our methods. MethodsIn 1997, the first successful adult LDLTs used a left and subsequently a right lobe. However, congestion in the anterior segment of right-lobe grafts prompted us to initiate reconstruction of middle hepatic venous tributaries in 1998. Dual LDLT grafts using 2 left lobes were developed in 2000 to solve graft-size insufficiency and minimize donor risk. The indications for adult LDLT were broadened to near complete obstruction of the portal vein by application of intraoperative cine-portography and portal vein stenting in 2004. ABO-incompatible adult LDLT was initiated in 2008 to overcome the blood group barrier between recipient and donor. ResultsWith various innovations at our institution, 317 LDLTs were performed yearly in 2010 and 2011: 301 in 2010 and 298 in 2011. The most common primary diseases was hepatitis B virus-related liver cirrhosis with or without hepatocellular carcinoma (64.3%). The most common graft types were right hemiliver (82.6%). There has been no donor mortality. ABO-incompatible LDLT cases were 11.0% of the total. In-hospital mortality in 2011 was 2.5% (n = 8; adult 6, pediatric 2). ConclusionInnovations in operative techniques and perioperative care as well as dedicated team members have made it possible to perform more than 300 LDLTs per year consecutively with excellent outcomes.

Non‐inpatient parenteral antibiotic therapy in febrile adults

Non-inpatient care is becoming an increasingly attractive option in many therapeutic areas, including the treatment of infections in patients with haematological malignancies. The choice of antibiotics for this care is governed by infection patterns and experience within particular institutions. There is an increase in infections caused by Gram-positive pathogens due to the long-term use of tunnelled catheters and intensive, punishing chemotherapy regimens. Patients suitable for non-inpatient care include both long- and short-term patients who fulfil specific clinical and social criteria. Haematological malignancy patients are often suitable for this type of care. Benefits for patients include improved quality of life, while benefits for the clinician include effective, safe care as well as reduced costs and greater bed availability. The glycopeptide teicoplanin has been assessed for use in non-inpatient care, and is particularly suitable due to its long half-life, no need for monitoring and its activity against Gram-positive pathogens. A comparative study of a teicoplanin-ciprofloxacin combination was conducted in inpatients, followed by a cohort study in non-inpatients. This combination was found to be clinically and microbiologically effective, suitable for non-inpatient administration and generated cost savings due to early discharge. The organization of a non-inpatient service demands dedicated team members, with well-defined roles and a designated treatment area. The day ward is the focus of care, which can then take place in the day ward or in the patient's home. Good communication between immediate and wider team members, and patient education are cornerstones of a successful service.