Interdisciplinary Case Conference Research Articles

An organisation working mainly reactively instead of proactively: a qualitative study of how frail users of home care services and their next of kin experience crises

BackgroundFrail people receiving home care services face an increased risk of developing crisis, which can result in adverse events, coercive measures, and acute institutionalisation. The prevalence of frailty is expected to increase due to the ageing population in most countries. However, our knowledge of the process leading to crises among frail community-dwelling patients remains limited. The aim of our study was to explore how users of home care services and their next of kin experienced crises and how these crises were approached by home care services.MethodsA qualitative explorative design with 21 interviews was conducted. We explored crises within the last year that had led to an acute institutionalisation (hospital or nursing home) or to an unstable situation with high risk of institutionalisation. Systematic text condensation (STC) was used to analyse the data.ResultsOur findings are summarised into one overarching theme; an organisation working mainly reactively instead of proactively, which is supported by four subthemes: (1) insufficient communication—a determinant of crises, (2) the lack of a holistic approach, (3) a sense of being a burden, and (4) the complexity of crises. The reactive approach is demonstrated in the participant’s experience of insufficient communication and the lack of a holistic approach from the service, but also in the user’s sense of being a burden, which seems to be reinforced by the experienced busyness from the staff in the home care services. This reactive approach to crises seems to have contributed to difficulties in detecting the various stressors involved in the complex process leading to crisis.ConclusionsOur findings suggest that home care services tend to be characterised by a reactive approach to rising instability and the development of crises for users. This can be interpreted as an emergent property of the organisation and the adaptation towards exceeding demands due to insufficient capacity in health care services. We recommend the use of multicomponent care programmes comprising interdisciplinary case conferences in home care services to implement a cultural change that can shift the service from a reactive, fragmented, and task-oriented approach to a more proactive approach.

Experiences of patients with advanced chronic diseases and their associates with a structured palliative care nurse visit followed by an interprofessional case conference in primary care – a deductive-inductive content analysis based on qualitative interviews (KOPAL-Study)

BackgroundChronic, non-malignant diseases (CNMD) like chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and dementia in advanced stages are very burdensome for patients. Timely palliative care with strong collaboration between general practitioners (GPs) and specialist palliative home care (SPHC) teams can reduce symptom burden, hospitalization rates, hospitalization costs and overall healthcare costs. The KOPAL-study on strengthening interprofessional collaboration for patients with palliative care needs tested the effect of an intervention comprising of a SPHC nurse assessment and an interprofessional case conference. This qualitative evaluative study explores patients’, proxies’ and their associates’ motivation to participate in the KOPAL-study and views on the (benefits of the) intervention.MethodsWe interviewed 13 male and 10 female patients as well as 14 proxies of patients with dementia and six associates of study participants using a semi-structured interview guide. All interviews were digitally recorded, transcribed verbatim and analysed with deductive-inductive qualitative content analysis.ResultsMotivation for participation was driven by curiosity, the aim to please the GP or to support research, respectively to help other patients. Few interviewees pointed out to have expected positive effects for themselves. The nurse visit was evaluated very positively. Positive changes concerning health care or quality of life were reported sparsely. Most study participants did not prepare for the SPHC nurse assessment. They had no expectations concerning potential benefits of such an assessment, the interdisciplinary case conference and an early integration of palliative care. The majority of interviewees reported that they did not talk about the nurse visit and the interprofessional case conference with their GPs.ConclusionOur results lead to the conclusion that SPHC nurses can serve as an advocate for the patient and thereby support the patients’ autonomy. GPs should actively discuss the results of the interdisciplinary case conference with patients and collaboratively decide on further actions. Patient participation in the interdisciplinary case conference could be another way to increase the effects of the intervention by empowering patients to not just passively receive the intervention.Trial registrationDRKS00017795 German Clinical Trials Register, 17Nov2021, version 05.

PReventing and Approaching Crises for frail community-dwelling patients Through Innovative Care (PRACTIC): protocol for an effectiveness cluster randomised controlled trial

BackgroundDemographic changes, with an increasing number and proportion of older people with multimorbidity and frailty, will put more pressure on home care services in municipalities. Frail multimorbid people receiving home care services are at high risk of developing crises, defined as critical challenges and symptoms, which demand immediate and new actions. The crises often result in adverse events, coercive measures, and acute institutionalisation. There is a lack of evidence-based interventions to prevent and resolve crises in community settings.MethodsThis is a participatory action research design (PAR) in a 6-month cluster randomised controlled trial (RCT). The trial will be conducted in 30 municipalities, including 150 frail community-dwelling participants receiving home care services judged by the services to be at risk of developing crisis. Each municipality (cluster) will be randomised to receive either the locally adapted TIME intervention (the intervention group) or care as usual (the control group). The Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) is a manual-based, multicomponent programme that includes a rigorous assessment of the crisis, one or more interdisciplinary case conferences, and the testing and evaluation of customised treatment measures. PAR in combination with an RCT will enhance adaptations of the intervention to the local context and needs. The primary outcome is as follows: difference in change between the intervention and control groups in individual goal achievement to resolve or reduce the challenges of the crises between baseline and 3 months using the PRACTIC Goal Setting Interview (PGSI). Among the secondary outcomes are the difference in change in the PGSI scale at 6 months and in neuropsychiatric symptoms (NPSs), quality of life, distress perceived by professional carers and next of kin, and institutionalisation at 3 and 6 months.DiscussionThrough customised interventions that involve patients, the next of kin, the social context, and health care services, crises may be prevented and resolved. The PReventing and Approaching Crises for frail community-dwelling patients Through Innovative Care (PRACTIC) study will enhance innovation for health professionals, management, and users in the development of new knowledge and a new adapted approach towards crises.Trial registrationClinicalTrials.gov identifier: NCT05651659. Registered 15.12.22.

The Duplicity of Incidents: Cervical Lymphatic Malformation in two Newborns

We report on two neonates born the same day, both with an isolated cervical lymphatic malformation. Cervical masses were detected by ultrasound late in the third trimester. Following interdisciplinary case conferences, a caesarean section in the presence of a neonatal team was the chosen delivery mode in both cases. Delivery and transition of the newborns were uneventful. The suspected diagnosis was confirmed by postnatal MRIs, which demonstrated neither associated malformations nor compression of vital structures. Therefore, an expectant approach was chosen for the newborn with the smaller lesion. The other newborn featured a sizeable lymphatic malformation, and due to consecutive head tilt, sclerotherapy was initiated in its second week of life. Our case report outlines the challenges of a rare connatal malformation. Guidelines are often missing. Individual decisions regarding delivery mode, diagnostics and therapy have to be made on an interdisciplinary basis and patients as well as parents need counseling and support over a long period. All the more significant is good, interdisciplinary collaboration between the involved disciplines.

Medication optimization in nursing homes: the impact of education and interdisciplinary case conferencing

Introduction: Potentially inappropriate prescribing has shown to be highly prevalent in older adults, especially in nursing home residents. Previous research, such as the Come-On study, proved that a complex intervention, containing an educational component and interdisciplinary case conferencing, is effective in reducing this phenomenon. 
 Policy context and objective: Awaiting the structural implementation supported by the government, an initiative was set up in West-Flanders to locally implement such an intervention and explore its impact.
 Target population: This study targeted nursing home residents and nursing home staff.
 Innovation, impact, outcomes: The intervention included three components: 1) education of nursing home staff by the pharmacist with regard to medication use in nursing home residents, 2) interdisciplinary case conferencing during which medication plans of residents were discussed (i.e. medication review) by the resident’s general practitioner (or the nursing home’s coordinating physician), a nurse, and the pharmacist, and 3) intervision across nursing homes to discuss experiences. Nursing homes were encouraged to involve residents and family members as much as possible (e.g. to invite them to the interdisciplinary case conference). For each case conference, nursing homes were instructed to report the duration, the identified (potential) drug-related problems, and the proposed medication changes. Throughout the study, financial incentives were provided for pharmacists and nursing homes.
 Quantitative data were analyzed descriptively, while qualitative data were analyzed inductively. Furthermore, an economic evaluation was performed.
 Eight nursing homes participated in the study. Nursing home staff indicated to have better medication-related knowledge and to be more aware of potential drug-related problems thanks to their participation in the project. They also experienced better communication between all involved healthcare professionals and with residents and their families.
 So far, data with regard to the interdisciplinary case conferences has been collected from five nursing homes, encompassing 266 nursing home residents. An interdisciplinary case conference lasted on average about 30 minutes per resident. For 60% of these nursing home residents, at least one medication change was implemented (e.g. stopping of a drug, change of administration time or route, change of dosage form). The five most frequently stopped drugs included 1) vitamins and supplements, 2) psychotropic drugs, 3) pain killers, 4) PPIs, and 5) antihypertensive drugs. On average, this resulted in a saving of €105 per year per resident.
 It was noted that general practitioners only participated in the case conferences in one nursing home. Likewise, residents nor family members were present during the interdisciplinary meetings. Nevertheless, residents (and families) were interviewed regarding their medication use in preparation of the conference and were informed about medication changes afterwards. 
 Transferability and conclusion: The intervention was shown to be effective in optimizing the medication use of nursing home residents. Following steps will focus on the implementation of the intervention in a higher number of nursing homes, as well as in other home replacing settings. Additionally, opportunities for involvement of residents and their families, as well the participation of general practitioners will be further investigated.
 Key words: Residential care, interdisciplinary case conferences, inappropriate prescribing, medication review

Improving Diversity, Equity, and Inclusion Content in Pediatrics Grand Rounds.

Grand rounds (GR) is a quintessential component of medical education across the spectrum from undergraduate medical education to continuing medical education for established physicians with a goal of enhancing knowledge, changing physician behavior, and improving patient outcomes. The purpose and scope of GR has undergone many iterations over the hundreds of years of its practice and previous work has aimed to enhance its educational impact, 1 Van Hoof, Thomas MD, EdD, J. Monson, Robert PhD, J. et al. A Case Study of Medical Grand Rounds: Are We Using Effective Methods?. Academic Medicine. 2009; Volume 84 (August): 1144-1151https://doi.org/10.1097/ACM.0b013e3181ad1c0e Crossref Scopus (33) Google Scholar including innovations that seek to educate about the origin and ongoing consequences of the health crises of systemic racism and other structural inequities. 2 Perdomo J. Tolliver D. Hsu H. et al. Health Equity Rounds: An Interdisciplinary Case Conference to Address Implicit Bias and Structural Racism for Faculty and Trainees. MedEdPORTAL. 2019; 15: 10858https://doi.org/10.15766/mep_2374-8265.10858 Crossref PubMed Scopus (39) Google Scholar A primary audience for GR is established mid- and late-career faculty, an educational target group perhaps more in need of DEI pedagogy than our earliest medical career learners. 3 Rosenkranz Kari M. Arora Tania K. Termuhlen Paula M. et al. Diversity, Equity and Inclusion in Medicine: Why It Matters and How do We Achieve It?. Journal of Surgical Education. 2021; Volume 78 (ISSN 1931-7204): 1058-1065https://doi.org/10.1016/j.jsurg.2020.11.013 Crossref Scopus (34) Google Scholar Previous work on improving anti-racist content in medical education recognizes this group as in need of particular focus. 4 Blankenburg R. et al. Dismantling racism: Association of Pediatric Program Directors’ Commitment to Action. Academic Pediatrics. 2020; 20: 1051-1053 Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Development of presentations that consistently and specifically address aspects of DEI is essential to sustainably re-orienting medical education to address health equity.

Autism Spectrum Disorders in Adulthood: Empirical Findings on Comorbidities, Differential Diagnoses, and the Clinical Utility of the AQ

DDX and comorbidities were recorded with standardized scales in an autism outpatient clinic in 106 individuals. The AQ was tested against the expert judgment of an interdisciplinary case conference using ROC analysis. Affective disorders were common in both groups (48%); other DDX were phobias (33%) and personality disorders (22%). The AQ showed an AUC of 0,527 with sensitivity/specificity of 70%/35%. Adults suspected of having autism are highly burdened by DDX and comorbidities. An interdisciplinary diagnostic procedure based on standardized scales is useful, whereas the AQ hardly differentiates between persons with and without ASD.

Interdisciplinary extremity board in the treatment of complex injuries

Interdisciplinary case conferences are well-established in the field of oncology in order to provide the best possible treatment for patients with complex disease patterns which overlap several disciplines. After studying the available literature the aims, indications, frequency, patient enrolment and documentation modalities, disciplines necessary to create the reconstruction plan and evaluation parameters of the board, were agreed in an interdisciplinary discussion among colleagues. The utilization of the extremity board and demographic features of the cases presented in the extremity board within the first 6months were subsequently descriptively analyzed. The agreed primary aim of an extremity board is the timely and transparent preparation of ahigh-quality holistic reconstruction plan for optimized treatment of achallenging patient collective with complex injuries of the extremities. Decisive interfaces of an extremity board are the participation of interdisciplinary disciplines, established enrolment and documentation modalities and a longitudinal analysis of parameters of the acute medical treatment, the long-term function and quality of life of those affected. The patient collective so far mostly includes men under 40years old with traumatic soft tissue defects and combined injuries. On average, reconstruction plans for 1-2patients were approved in an interdisciplinary team per session. The extremity board serves as aplatform for coordinated planning of treatment for patients with complex injuries. The limited personnel and time resources represent the greatest challenge for the successful implementation. The extremity board enables ahigh degree of interdisciplinary networking. The digital registration and documentation modality within the internal hospital documentation system is of utmost relevance. The preparation of the reconstruction plan is of decisive importance for the qualitative success of treatment and the restoration of function. The longitudinal analysis of appropriate parameters is imperative to measure the quality of treatment.

Comparative outcome of different treatment options for fragility fractures of the sacrum

BackgroundFragility fractures of the sacrum (FFS) have been detected more and more frequently in recent times, and the incidence will continue to increase due to increasing life expectancy. The aim of this study was to compare the clinical outcome of conservative, interventional and surgical treatment of FFS.MethodsRetrospectively, 292 patients (276 women, 16 men) with confirmed FFS were followed up over a period of 2 years. The age of the women was Ø 81.2 (58 - 99) and that of the men Ø 78.1 (76 - 85) years. The pain was quantified using a VAS. Fractures were classified in accordance with the Rommens and Hofmann and with the Denis classification using conventional X-rays, CT and MRI. A QCT of the lumbar spine was performed to quantify bone mineral density. Concomitant diseases of every patient were recorded. An interdisciplinary case conference determined the individual treatment concept considering the age, type of fracture, pain level and comorbidities with classification into conservative, interventional (any type of sacroplasty) or surgical treatment. Over the course pain and independence were measured, complications and patient satisfaction were documented. A vitamin D determination was done, and existing comorbidities were included.ResultsPatients with a pain level of ≤5 benefited from the conservative therapy measures, with pain levels > 5 significantly delaying the development of mobility. After sacroplasty, the pain reduced significantly, which caused a rapid improvement in mobility without any significant difference being found between vertebro- (VSP), balloon (BSP), radiofrequency (RFS) and cement sacroplasty (CSP). In terms of pain reduction and mobilization, the surgical treated patients benefited from osteosynthesis, although more complex fracture types with lumbopelvic stabilization took longer. Overall, there were no deaths during the hospital stay. Mortality after 12 months was 21.7% for the conservative, 8.4% for the interventional and 13.6% for the surgical therapy group; the differences are significant. For patients in the conservative therapy group who were difficult to mobilize due to pain, the mortality increased to 24.3%. Over 24 months, patients achieved the best independence after sacroplasty. At 12 and 24 months, subjective satisfaction with the therapies was best after sacroplasty, followed by osteosynthesis and conservative measures. All patients had a pronounced vitamin D deficiency and manifest osteoporosis. Cardiovascular pathologies were the main concomitant diseases.ConclusionsPatients with FFS with a low level of pain benefit from conservative therapy measures, whereby complications and mortality increase significantly in the case of persistent immobilizing pain. Patients with an unacceptable level of pain resulting from non-dislocated fractures benefit significantly from sacroplasty. Patients with unstable and displaced fractures (Rommens and Hofmann type III and IV) should be operated on promptly. Different techniques are available for sacroplasty and osteosynthesis, which lead to an improvement of independence and a reduction in mortality.

Developing tailored theoretically informed goal-setting interventions for rehabilitation services: a co-design approach

BackgroundSeveral active ingredients contribute to the purposes and mechanisms of goal-setting in rehabilitation. Active ingredients in the goal-setting process include, interdisciplinary teamworking, shared decision-making, having meaningful and specific goals, and including action planning, coping planning, feedback, and review. Clinicians have expressed barriers and enablers to implementing these active ingredients in rehabilitation teams. Interventions designed to improve goal-setting practices need to be tailored to address context specific barriers and enablers. Attempts to understand and enhance goal-setting practices in rehabilitation settings should be supported using theory, process models and determinant frameworks. Few studies have been undertaken to enhance goal-setting practices in varied case-mix rehabilitation settings.MethodsThis study is part of a larger program of research guided by the Knowledge to Action (KTA) framework. A multisite, participatory, codesign approach was used in five sites to address three stages of the KTA. (1) Focus groups were conducted to understand barriers and enablers to implementing goal-setting at each site. Following the focus groups three staff co-design workshops and one consumer workshop were run at each site to (2) adapt knowledge to local context, and to (3) select and tailor interventions to improve goal-setting practices. Focus groups were analysed using the Theoretical Domains Framework (TDF) and informed the selection of behaviour change techniques incorporated into the implementation plan.ResultsBarriers and enablers identified in this study were consistent with previous research. Clinicians lacked knowledge and understanding of the differences between a goal and an action plan often confusing both terms. Clinicians were unable to demonstrate an understanding of the importance of comprehensive action planning and review processes that extended beyond initial goal-setting. Interventions developed across the sites included staff training modules, a client held workbook, educational rehabilitation service flyers, interdisciplinary goal-based case conference templates, communication goal boards and a key worker model. Implementation plans were specifically established for each site.ConclusionsRehabilitation teams continue to struggle to incorporate a truly client-centred, interdisciplinary model of goal-setting in rehabilitation. Whilst clinicians continue to lack understanding of how they can use aspects of goal-setting to enhance client outcomes and autonomy in rehabilitation settings.

Post-COVIDLMU: implementation and evaluation of an interdisciplinary and cross-sectoral healthcare and research network for evidence-based treatment of patients with severe post-COVID syndrome

Post-COVIDLMU ist ein interdisziplinäres und sektorenübergreifendes Versorgungs- und Forschungsnetzwerk des LMU(Ludwig-Maximilians-Universität)-Klinikums. Der Schwerpunkt liegt auf der Behandlung und Erforschung komplexer und schwerer Post-COVID(„coronavirus disease“)-Syndrom-Fälle bei Erwachsenen. Die Behandlung dieser Patientengruppe erfolgt interdisziplinär unter Einbezug zahlreicher Fachkliniken des LMU-Klinikums. Ergänzt wird das universitäre Behandlungsangebot durch moderne telemedizinische Sprechstunden, interdisziplinäre Fallkonferenzen unter Beteiligungsmöglichkeit der zuweisenden Kollegen*innen sowie der Möglichkeit für Patient*innen, an Studien der medizinischen Forschung zum Post-COVID-Syndrom teilzunehmen. Das LMU-Klinikum kooperiert eng mit niedergelassenen Ärzten*innen sowie verschiedenen Rehaeinrichtungen in Deutschland.

Diagnostik seltener Erkrankungen in der Pädiatrie

Rare diseases are frequent in pediatrics. In university children‘s hospitals almost 60% of children treated as inpatients suffer from rare diseases. As rare diseases in pediatrics are often severe, complex and chronic, affected families have a high disease burden. The burden is particularly severe in cases with an unclear or unknown diagnosis because the uncertainty of the child’s prognosis adds to the burden of the current suffering and in some cases the molecular diagnosis will enable a new targeted treatment option. The innovation fund project TRANSLATE-NAMSE, financed by the Federal Joint Committee (GBA), has previously evaluated the possibility of improved diagnostics for children and adolescents with undiagnosed rare diseases. Based on interdisciplinary case conferences and supported by the implementation of exome sequencing, 30% of previously uncertain diagnoses could be definitively clarified.

Chronic low back pain-user types of ambulatory care : Cluster analysis of the utilization of ambulatory health care resources with administrative data of the AOK Baden-Württemberg

HintergrundChronische Kreuzschmerzen (engl. „chronic low back pain“; Abk. CLBP) zählen zu den häufigsten muskuloskeletalen Erkrankungen. Die ambulante Regelversorgung sieht bisher keine strukturierte multimodale Versorgung vor, wobei eine multimodale Therapie empfohlen wird.Ziel der ArbeitEs sollte die Inanspruchnahme ambulanter Regelversorgung im ersten Jahr von neu erkrankten Patienten mit CLBP hinsichtlich des multimodalen Behandlungsansatzes exploriert und Nutzertypen bestimmt werden.Material und MethodenEine Two-step-Clusteranalyse wurde mit Routinedaten von 11.182 inzidenten Fällen durchgeführt. Das Alter lag zwischen 18 und 65 Jahren und Daten von vier aufeinander folgenden Quartalen je Patient wurden analysiert. Anhand der Abrechnungsdaten von Orthopäden, Schmerztherapeuten, Psychotherapeuten, Heilmitteln, Schmerzmedikamenten und Opioiden wurden die Cluster ermittelt. Merkmale der Versorgungsstruktur und der Versicherten lieferten die weiteren Ergebnisse.ErgebnisseDie Analyse ergab vier Nutzertypen: 39,7 % nahmen keine fachärztliche Versorgung und wenige Heilmittel in Anspruch; 37,3 % wurden orthopädisch versorgt; 15,6 % nahmen orthopädische und schmerztherapeutische Versorgung in Anspruch; 7,4 % wurden orthopädisch, schmerz- und/oder psychotherapeutisch versorgt. Charakteristisch für eine multimodale Inanspruchnahme war: weiblich, hoher Schmerzmittelverbrauch (M = 143,94 DDD), hoher Opioidverbrauch (M = 37,12 DDD), hohe Heilmittelkosten (M = 631,79 €), Akupunktur, Antidepressiva, Hospitalisierung, interdisziplinäre Fallkonferenzen und Konsultationen bei Neurologen. 60,4 % der Studienpopulation nahmen Schmerzmittel ein.DiskussionDas Clusterverfahren zeigte unterschiedliche Nutzertypen. Die empfohlene multimodale Therapie erhielten circa 23 % der Studienpopulation.

Abstract 14689: Optimal Prenatal Care Coordination is Associated With Fewer Pre-operative Risk Factors in Babies With a Prenatal Diagnosis of HLHS

Introduction: Prenatal diagnosis (PD) of congenital heart disease permits coordination of care to optimize postnatal outcomes. Using phase II registry data from the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC), we sought to identify associations between prenatal care coordination (PNC) and pre-operative status among infants with HLHS and variants intended for Stage I Norwood or hybrid palliation. Hypothesis: We hypothesized that suboptimal PNC would be associated with worse pre-operative status. Methods: The NPC-QIC database was queried for all instances of prenatally diagnosed HLHS and variants intended for Stage 1 Norwood or hybrid palliation from 2016 through 2019. Demographic and clinical data pertaining to the prenatal period through the first birthday were obtained. Optimal PNC was defined as (1) a completed interdisciplinary case conference prior to delivery and (2) a note in the medical record documenting closed-loop communication between the OB and cardiology teams. Associations between PNC and outcomes were identified. Results: Among 1441 registry patients with HLHS and variants, 1242 (86%) had PD. Among patients with PD, optimal PNC was achieved in 68%. Preoperatively, infants without optimal PNC were more likely to have any adverse event (50% vs 40%, p<0.001), receive inotropes (19% vs 13%, p=0.007), require mechanical ventilation (22% vs 16%, p=0.016), and were less likely to feed enterally (53% vs 67%, p <0.001). Lower socio-economic status (SES) was associated with a lower likelihood of PD (p<0.001), and African-American race was associated with a lower likelihood of optimal PNC (p=0.006). Conclusions: Among prenatally diagnosed infants with HLHS and variants, optimal PNC was associated with fewer preoperative risk factors. There also appear to be disparities in PD related to SES and in PNC related to race. Additional study is required to understand the complex interplay between PNC and clinical outcomes, as well as identify and address barriers to PD and optimal PNC.

Interdisciplinary COVID board for patients with SARS-CoV-2-triggered hyperferritinemic Inflammation

HintergrundPatienten mit schwerer COVID-19-Erkrankung entwickeln eine hyperferritinämische Inflammation, ein sepsisähnliches Immundysregulationssyndrom.MethodeRetrospektive Kohortenanalyse nach Therapiestratifizierung in einer standortübergreifenden telemedizinischen Fallkonferenz. Frühzeitige, standardisierte Identifizierung von Patienten mit einem Risiko für einen schweren Verlauf (COVID-Inflammation-Score; CIS) und Intubationsvermeidung mit Schwerpunkt auf nichtinvasive Ventilation (NIV) sind Kernelemente des Behandlungsalgorithmus. Patienten mit lebensbedrohlicher Inflammation wurde ein individueller Heilversuch mit dem Immunmodulator Ruxolitinib angeboten.ErgebnisseZwischen 04.03.2020 und 26.06.2020 wurden 196 COVID-19-Patienten behandelt. Der Altersmedian (70 Jahre) und die Komorbidität waren im Interstudienvergleich hoch. Die Gesamtmortalität lag bei 17,3 %, wobei bei der Hälfte der verstorbenen Patienten eine A‑priori-Therapielimitierung festgelegt war. Das CIS-Monitoring der mit Ruxolitinib behandelten Hochrisikopatienten (n = 20) ergab nach 5, 7 und 15 Tagen eine Inflammationssuppression um 42 % (15–70), 54 % (15–77) und 60 % (15–80). In dieser Gruppe lag die Mortalität bei 20 % (4/20). Die Gesamtmortalität adjustiert auf Patienten mit intendierter Maximaltherapie lag bei 8,7 % (17/196).SchlussfolgerungDie COVID-19-Pneumonie mit hyperferritinämischer Inflammation ist verwandt mit der Makrophagen-Aktivierungssyndrom-ähnlichen Sepsis. Eine interdisziplinäre Fallkonferenz als Qualitätsinstrument der Intensivmedizin zur Erfassung seltener sepsisähnlicher Krankheitsbilder wird vorgestellt.

Effectiveness of a Technology-Enhanced Integrated Care Model for Frail Older People: A Stepped-Wedge Cluster Randomized Trial in Nursing Homes.

Background and ObjectivesThe objective of this study was to evaluate the impact of an information and communication technologies (ICT)-enhanced, multidisciplinary integrated care model, called Systems for Person-centered Elder Care (SPEC), on frail older adults at nursing homes.Research Design and MethodsSPEC was implemented at 10 nursing homes in South Korea in random order using a stepped-wedge design. Data were collected on all participating older residents in the homes before the first implementation and until 6 months after the last implementation. The 21-month SPEC intervention guided by the chronic care model (CCM) consists of 5 strategies: comprehensive geriatric assessment, care planning, optional interdisciplinary case conferences, care coordination, and a cloud-based ICT tool along with a free messaging app. The primary outcome was quality of care measured by a composite quality indicator (QI) from the interRAI assessment system. Usual care continued over the control periods. Nursing home staff were not blinded to the intervention.ResultsThere were a total of 482 older nursing home residents included in the analysis. Overall quality of care measured by the composite QI was significantly improved (adjusted mean difference: −0.025 [95% CI: −0.037 to −0.014, p < .0001]). The intervention effect was consistent in the subgroup analysis by cognition and activities of daily living. There were no important adverse events or side effects.Discussion and ImplicationsThe SPEC, a CCM-guided, ICT-supported, multidisciplinary integrated care management intervention, can improve the quality of care measured by health and functional outcomes for frail older persons residing in nursing homes with limited health care provision.Clinical Trials Registration NumberISRCTN11972147

Use of the Multidisciplinary Specialised Case Conference at the Freiburg Orbital Centre

The treatment of tumors increasingly takes place in specialised interdisciplinary centres. Therapeutic decisions are usually made at case conferences. Ophthalmologists, oromaximillofacial surgeons, ENT physicians, neurosurgeons, as well as pediatricians, radiotherapists and radiologists are all involved in the treatment of orbital diseases. The aim of this article is to present the concept of a multidisciplinary case conference for orbital diseases and to analyse case numbers, indications, and the influence on the patient's therapy. We analysed an anonymized data set of patients who presented in the case conference of the University Hospital Freiburg from 2008 to 2018 with regard to clinical diagnosis, histological diagnoses, number of surgical interventions, and number of interdisciplinary therapy decisions. From 2008 to 2018, 545 patients were presented in a weekly conference. Of these, 453 were available for anonymous evaluation. The median age was 56 years (quartiles 41; 69). The most frequent indication was an orbital tumour of unclear malignancy (n = 52; 11%). Further indications included Grave's orbitopathy (n = 39; 9%), orbital pseudotumour (n = 36; 8%), cranial nerve palsy (n = 22; 5%), and orbital lymphoma (n = 22; 5%). The most frequent histological diagnoses were B-cell lymphoma (n = 10; 2%), venous malformation (cavernoma, n = 8; 2%), marginal zone lymphoma (n = 8; 2%), and squamous cell carcinoma (n = 6; 1%). An interdisciplinary therapeutic approach was defined for 174 patients. A high demand for the interdisciplinary case conference was demonstrated. The high rate of primary or secondary interdisciplinary decisions indicates the value of such a conference. Hence, the patient is spared multiple examinations in the individual specialist areas and quick and effective therapy decisions can be achieved.

Process evaluation of a complex intervention to optimize quality of prescribing in nursing homes (COME-ON study)

BackgroundThe COME-ON study was a cluster-controlled trial of a complex intervention that consisted of a blended training program, local interdisciplinary meetings, and interdisciplinary case conferences in Belgian nursing homes. The intervention was associated with significant improvements in the appropriateness of prescribing. The aims of this study were to describe the implementation of the intervention and to explore the experiences of participants, for the purpose of identifying factors associated with implementation and perceived impact and to draw lessons for future implementation.MethodsWe performed a mixed-method process evaluation. Questionnaires and reports were used to collect quantitative data on implementation and experiences from the 24 NHs and participating healthcare professionals (coordinating physicians, general practitioners, pharmacists, and nurses) in the intervention group. Multidisciplinary focus groups focusing on factors associated with implementation and perceived impact were conducted in 11 NHs.ResultsOverall, the rate of implementation and the satisfaction of participants were good, despite some variability between NHs and HCPs. Although perceived impact on nursing home residents varied, most participants perceived a positive impact for themselves. Factors associated with implementation and perceived impact were identified at different levels: intervention, healthcare professionals, organization, and external context. The interdisciplinary and face-to-face approaches were recognized as key elements for the success of the intervention, despite organizational constraints. The attitude of general practitioners was identified both as a barrier to and a facilitator for implementation and its success. The professional role and competency of the pharmacist influenced perceived impact. The pre-existing relationships between HCPs and the presence of a leader facilitated implementation and perceived impact. Remuneration was deemed necessary for the study and for future implementation.ConclusionsOverall, the intervention, and more specifically its interdisciplinary aspect, was well implemented and appreciated by HCPs. This probably contributed to the positive effect on the appropriateness of prescribing. Future implementation must take into account the various factors found to affect implementation and perceived impact, in order to maximize effect and sustainability.Trial registrationCurrent Controlled Trials ISRCTN66138978; registered 18 November 2015, retrospectively registered, https://www.isrctn.com/ISRCTN66138978

Interdisciplinary medication review to improve pharmacotherapy for patients with intellectual disabilities.

Background Patients with intellectual disabilities is an underserved patient group that have poor abilities to express their health complaints. Objective The aim of this study was to improve pharmacotherapy in patients with intellectual disability, by the use of medication reviews and interdisciplinary case conferences. Setting Patients with intellectual disabilities receiving home care services in Oslo, Norway. Method Patients receiving home care services were recruited by a nurse. A clinical pharmacist conducted medication reviews, and thereafter, the patients' general practitioner, nurse/social educator and clinical pharmacist discussed the pharmacotherapy at an interdisciplinary case conference. Patient demographics, prescribed drugs (strength, dose, indication) and drug-related problems (DRPs) were recorded. Main outcome measure Patient outcomes and actions taken to resolve DRPs 6weeks after the case conference. Results Forty patients (34-77years) with intellectual disabilities consented to medication reviews. They used on average 12 different drugs (range 5-23). The most commonly prescribed drugs were CNS-active drugs: analgesics (25 patients), antiepileptics (23 patients) and anxiolytics (21 patients). In total, 27 patients used between 3 and 7 different CNS-active drugs. The clinical pharmacist identified 178 DRPs in 39/40 patients (average 4.5 DRPs, range 0-13). DRPs for 30% of all prescribed drugs were resolved (145/481). Overall, 11% of drugs were deprescribed, 8% required therapeutic monitoring/follow-up, and either the dosage, formulation or route of administration were changed for 7% of the drugs. Conclusions Patients with intellectual disabilities receiving home care services were prescribed many unnecessary drugs and needed adjustment of pharmacotherapy for about one third of their prescribed drugs. The interdisciplinary case conferences improved pharmacotherapy for this vulnerable patient group.

A Stepwise Pharmacist-Led Medication Review Service in Interdisciplinary Teams in Rural Nursing Homes.

Background: The provision of responsible medication therapy to old nursing home residents with comorbidities is a difficult task and requires extensive knowledge about optimal pharmacotherapy for different conditions. We describe a stepwise pharmacist-led medication review service in combination with an interdisciplinary team collaboration in order to identify, resolve, and prevent medication related problems (MRPs). Methods: The service included residents from four rural Norwegian nursing homes during August 2016–January 2017. All residents were eligible if they (or next of kin) supplied oral consent. The interdisciplinary medication review service comprised four steps: (1) patient and medication history taking; (2) systematic medication review; (3) interdisciplinary case conference; and (4) follow-up of pharmaceutical care plan. The pharmacist collected information about previous and present medication use, and clinical and laboratory values necessary for the medication review. The nurses collected information about possible symptoms related to adverse drug reactions. The pharmacist conducted the medication reviews, identified medication-related problems (MRPs) which were discussed at case conferences with the responsible physician and the responsible nurses. The main outcome measures were number and types of MRPs, percentage agreement between pharmacists and physicians and factors associated with MRPs. Results: The service was delivered for 151 (94%) nursing home residents. The pharmacist identified 675 MRPs in 146 (97%) medication lists (mean 4.0, SD 2.6, range 0–13). The MRPs most frequently identified concerned ‘unnecessary drug’ (22%), ‘too high dosage’ (17%) and ‘drug interactions’ (16%). The physicians agreed upon 64% of the pharmacist recommendations, and action was taken immediately for 32% of these. We identified no association between the number of MRPs and sex (p = 0.485), but between the number of MRPs, and the number of medications and the individual nursing homes. Conclusion: The pharmacist-led medication review service in the nursing homes was highly successfully piloted with many solved and prevented MRPs in interdisciplinary collaboration between the pharmacist, physicians, and nurses. Implementation of this service as a standard in all four nursing homes seems necessary and feasible. If such a service is implemented, effects related to patient outcomes, interdisciplinary collaboration, and health economy should be studied.