Interdisciplinary Clinical Practice Research Articles

Introducing PALTmed: Empowering Interdisciplinary Clinical Practice in Post-Acute and Long-Term Care

Introducing PALTmed: Empowering Interdisciplinary Clinical Practice in Post-Acute and Long-Term Care

Clinical practice guideline: Interventions for Developmental Language Delay and Disorders.

Approximately 9.9 % of children present with difficulties in language development (DLD), 7.6 % without serious additional impairments and 2.3 % associated with languagerelevant comorbidities, e.g., hearing loss. Notably, in a consensus statement by experts in German-speaking countries, in the guideline presented here, and further in this article, all of these disorders are referred to as "developmental language disorders" (DLD), whereas the international consortium CATALISE only refers to those without comorbidities as DLD. DLDs are among the most commonly treated childhood disorders and, if persistent, often reduce educational and socio-economic outcome. Children in their third year of life with developmental language delay (late talkers, LT) are at risk of a later DLD. This German interdisciplinary clinical practice guideline reflects current knowledge regarding evidence-based interventions for developmental language delay and disorders. A systematic literature review was conducted on the effectiveness of interventions for DLD. The guideline recommends parent training (Hedges g = 0.38 to 0.82) for LTs with expressive language delay, language therapy (Cohen's d = -0.20 to 0.90) for LTs with additional receptive language delay or further DLD risk factors, phonological or integrated phonological treatment methods (Cohen's d = 0.89 to 1.04) for phonological speech sound disorders (SSDs), a motor approach for isolated phonetic SSDs (non-DLD), and for lexical-semantic and morpho-syntactic impairments combinations of implicit and explicit intervention approaches (including input enrichment, modeling techniques, elicitation methods, creation of production opportunities, metalinguistic- approaches, visualizations; Cohen's d = 0.89-1.04). Recom mendations were also made for DLD associated with pragmatic-communicative impairment, bi-/ multilingualism, hearing loss, intellectual disability, autism-spectrum disorders, selective mutism, language- relevant syndromes or multiple disabilities, and for intensive inpatient language rehabilitation. Early parent- and child-centered speech and language intervention implementing evidence-based intervention approaches, frequency, and settings, combined with educational language support, can improve the effectiveness of management of developmental language delay and disorders.

Adaptation of Interdisciplinary Clinical Practice Guidelines to Palliative Care for Patients with Heart Failure in Iran: Application of Adapte Method.

Clinical Practice Guidelines (CPGs) have been recommended to manage palliative care and take the best treatment measures and decisions. This study aimed to adapt the interdisciplinary CPG to provide palliative care for patients with Heart Failure (HF) in Iran based on the ADAPTE method. Guideline databases and websites were systematically searched up to April 2021 to determine appropriate publications related to the study topic. Followed by assessing the quality of the selected guidelines via the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II), those with appropriate standard scores were selected to be used in designing the initial draft of the adapted guideline. The developed draft contained 130 recommendations and was evaluated by a panel of interdisciplinary experts in terms of its relatedness, comprehensibility, usefulness, and feasibility in two phases of Delphi. In the first phase of Delphi, the adapted guideline was derived from five guidelines and evaluated by 27 interdisciplinary pundits working in the universities of Tehran, Isfahan, and Yazd cities. After the assessment in Delphi Phase 2, four recommendation categories were removed because they did not receive the required scores. Finally, 126 recommendation items were included in the developed guideline, which were classified into three main categories of palliative care features, essentials, and organization. In the present study, an interprofessional guideline was designed to enhance palliative care information and practice in patients with HF. This guideline can be administered as a valid tool for interprofessional team members to provide palliative care to patients with HF.

Is the Lifetime Malignancy Risk in United States Military Personnel Sustaining Combat-related Trauma Increased Because of Radiation Exposure From Diagnostic Imaging?

Patients with complex polytrauma in the military and civilian settings are often exposed to substantial diagnostic medical radiation because of serial imaging studies for injury diagnosis and subsequent management. This cumulative radiation exposure may increase the risk of subsequent malignancy. This is particularly true for combat-injured servicemembers who receive care at a variety of facilities worldwide. Currently, there is no coordinated effort to track the amount of radiation exposure each servicemember receives, nor a surveillance program to follow such patients in the long term. It is important to assess whether military servicemembers are exposed to excessive diagnostic radiation to mitigate or prevent such occurrences and monitor for carcinogenesis, when necessary. The cumulative amount of radiation exposure for combat-wounded and noncombat-wounded servicemembers has not been described, and it remains unknown whether diagnostic radiation exposure meets thresholds for an increased risk of carcinogenesis. We performed this study to (1) quantify the amount of exposure for combat-wounded servicemembers based on medical imaging in the first year after injury and compare those exposures with noncombat-related trauma, and (2) determine whether the cumulative dose of radiation correlates to the Injury Severity Score (ISS) across the combat-wounded and noncombat-wounded population combined. We performed a retrospective study of servicemembers who sustained combat or noncombat trauma and were treated at Walter Reed National Military Medical Center from 2005 to 2018. We evaluated patients using the Department of Defense Trauma Registry. After consolidating redundant records, the dataset included 3812 unique servicemember encounters. Three percent (104 of 3812) were excluded because of missing radiation exposure data in the electronic medical record. The final cohort included 3708 servicemembers who had combat or noncombat injury trauma, with a mean age at the time of injury of 26 ± 6 years and a mean ISS of 18 ± 12. The most common combat trauma mechanisms of injury were blast (in 65% [2415 of 3708 patients]), followed by high-velocity gunshot wounds (in 22% [815 of 3708 patients]). We calculated the cumulative diagnostic radiation dose exposure at 1 year post-traumatic injury in patients with combat-related trauma and those with noncombat trauma. We did this by multiplying the number of imaging studies by the standardized effective radiation dose for each imaging study type. We then performed analysis of variance for four data subsets (battle combat trauma, nonbattle civilian trauma, high ISS, and high radiation exposure [> 50 mSv]) independently. To evaluate whether the total number of imaging studies, radiation exposure, and ISS values differed between battle-wounded and nonbattle-wounded patients, we performed a pairwise t-test. The mean radiation exposure for combat-related injuries was 35 ± 26 mSv while the mean radiation exposure for noncombat-related injuries was 22 ± 33 mSv in the first year after injury. In the first year after trauma, 44% of patients (1626 of 3708) were exposed to high levels of radiation that were greater than 20 mSv, and 23% (840 of 3708) were exposed to very high levels of radiation that were greater than 50 mSv. Servicemembers with combat trauma-related injuries had eight more imaging studies than those who sustained noncombat injuries. Servicemembers with combat trauma injuries (35 ± 26 mSv) were exposed to more radiation (approximately 4 mSv) than patients treated for noncombat injuries (22 ± 33 mSv) (p = 0.01). We found that servicemembers with combat injuries had a higher ISS than servicemembers with noncombat trauma (p < 0.001). We found a positive correlation between radiation exposure and ISS for servicemembers. The positive relationship between radiation exposure and ISS held for combat trauma (r 2 = 0.24; p < 0.001), noncombat trauma (r 2 = 0.20; p < 0.001), servicemembers with a high ISS (r 2 = 0.10; p < 0.001), and servicemembers exposed to high doses of radiation (r 2 = 0.09; p < 0.001). These data should be used during clinical decision-making and patient counseling at military treatment facilities and might provide guidance to the Defense Health Agency. These recommendations will help determine whether the benefits of further imaging outweigh the risk of carcinogenesis. If not, we need to develop interdisciplinary clinical practice guidelines to reduce or minimize radiation exposure. It is important for treating physicians to seriously weigh the risk and benefits of every imaging study ordered because each test does not come without a cumulative risk. Level III, therapeutic study.

Balancing Protection and Progress in Pediatric Palliative Care Research: Stakeholder Perspectives.

Pediatric palliative care, including end-of-life care, remains a relatively new area of interdisciplinary clinical practice and research. Improving the multifaceted and complex care of children and their families involves research that (1) documents the experiences of children with serious illness, their families, and clinicians; (2) evaluates relationships between contextual factors and health outcomes; and (3) establishes a stronger foundation for child- and family-focused interventions to improve care. Partnership among stakeholders in family-focused research begins from design through conduct of the study. This partnership is the foundation of a dynamic research process that illuminates critical perspectives. We present a hypothetical pediatric palliative study; a qualitative descriptive study of the perspectives of adolescents and young adults with life-limiting illnesses and their parents after a discussion about an end-of-life decision. Pediatric palliative care researchers, institutional review board leaders, and the parent of a child who died comment on how to balance the obligations to improve clinical care and to protect participants in research. Their recommendations include recruiting a wide range of participants, differentiating emotional responses from harm, approaching potential participants as individuals, and seeking feedback from family advisory boards and designated reviewers with content expertise.

Physiological Mechanisms and Associated Pathophysiology of Dysphagia in Older Adults.

Dysphagia can be a common secondary sequela of neurological and neurodegenerative disorders in older adults. Early screening, identification, and management of dysphagia is essential to avoid serious complications, including malnutrition, dehydration, aspiration pneumonia; and promote quality of life. Although individuals of all ages may experience swallowing difficulties, dysphagia and its complications are more common in older adults. This literature review aims to provide an overview of the physiological mechanisms of normal swallowing in healthy individuals and age-related changes to swallowing function, the pathophysiology of dysphagia associated with three common neurological disorders affecting older adults (stroke, Parkinson's disease, and dementia), and implications for interdisciplinary clinical practice. Increased awareness of these issues may contribute to a more timely and efficient identification of older adults with dysphagia and to improve overall dysphagia management.

MLTI-04. The Role of the Outpatient Registered Nurse in the care of Brain Metastases

IntroductionBrain metastases is a complex disease, requiring a skilled clinical team to deliver medical and surgical care. The nurse is an integral member of the interdisciplinary team. Despite this, the role of the nurse in brain metastasis care has been neglected in the literature. Moreover, while education for neurology nursing exists, there is a paucity of literature defining the nursing care specific to brain metastases. The aim of this study was to describe the essential nursing functions in brain metastases within medical and surgical clinics.MethodsA working-group comprised of 2 registered nurses and a clinical nurse specialist in specialty brain metastases at Memorial Sloan-Kettering Cancer Center was formed. A KSA framework was used to develop a survey to assess nurses’ knowledge, skills, and attitudes regarding care of patients with brain metastases. 2 nurses were surveyed. Oncology nursing competencies were scored by medicine and surgical nurses for importance. Mean scores were calculated and ranked.ResultsNurses consistently reported care coordination; symptom management and monitoring parameters; knowledge of treatment modalities; and referrals as key competencies. More variably endorsed competencies included access devices (implanted port and Omaya); managing immunocompromised patients; and legal issues (consent).The nurses reported important knowledge includes screening and treatment guidelines; epidemiology; disease states including brain metastases and leptomeningeal disease; and tumor histology. Important skills include neurological exam; triage; critical thinking; and patient education. Important attitudes include being empathetic, communicative, positive, truthful, and realistic.ConclusionAs the care of the patient with brain metastases evolves, interdisciplinary clinical practice models with advanced nursing training must occur. As the repertoire of clinical trials for patients with brain metastases continues to expand, future studies should assess the effects of specialized nursing training on clinical outcomes in patients with brain metastases.

Revised curriculum of BDS with optional subjects: A thought process

There is a lot of saturation of conventional career opportunities when it comes to practicing in dental sciences. As a result, there is remarked observance of unemployment, drastic shifts in the careers which are seldom related to bachelor studies. This can often lead to a lack of job satisfaction and complete arrest of the conventional clinical practice. In such scenarios, it is necessary to seek for the alternative applied career options where the students as well as established dentists work and manifest expertise in such different career spectrums. In addition to the conventional subjects in masters of dental surgery, these courses might help the students who cannot afford the fees required for the masters. Exposure to the new fields can lead to better demand for jobs and the experience adds on to the expertise, better patient compliance, and development of better interpersonal and interdisciplinary clinical practice.

Principles guiding the development of clinical practice guidelines for medical genetics and genomics specialty

The development of clinical practice guidelines for medical genetics and genomics specialty is a key step in translating basic and clinical genetic research into evidence-based and precision clinical services. This paper briefly expounds the principles of writing high-quality and trustworthy clinical practice guidelines. According to these principles, the management framework, writing process, review and revision procedures, and application monitoring of medical genetic specialty guidelines are described. Systematic review of relevant literature for evidence applicable to the screening, diagnosis, counseling, treatment and prevention of specific genetic diseases is summarized. Specific requirements for writing and reviewing high-quality professional guidelines for medical genetics are introduced. These principles and requirements can ensure that the evidence-based methods and recommendations in the written guidelines conform to current international standards and have specific clinical purposes, scope of practice and time-tracking mechanism. Implementation of such guidelines can promote the translation of basic and clinical genetic research, promote cooperation of medical genetics and other clinical specialties and coordination of interdisciplinary clinical practice guidelines, and provide effective and safe clinical services for patients and their families.

Pyogenic spondylodiscitis : The quest towards aclinical-radiological classification.

Pyogenicspondylodiscitis(PS) is adebilitating condition laden with orthopedic and neurological complications. The choice of the best step in management is often delayed due to the controversy encompassing its multiple facets. Several classification systems were proposed in the literature to define optimal management; however, consensus was not achieved. The aim of this study was to review the literature and critically appraise the classification systems of PS and the rationale behind the classification criteria. Aliterature search was conducted in PubMed. Titles and abstracts of articles were searched using different synonyms of spondylodiscitis and its classification. No restrictions regarding language of publication or date of publication were applied. A total of 43papers with 5 encompassing 3 main classifications were found in the literature. These classifications were overlapping but different. They encompassed neurologic deficits, abscess formation and segmental instability, laboratory parameters and morphological changes in magnetic resonance imaging (MRI) as the most important factors used to classify PS, assess the severity and guide treatment. The current classification schemes overlap and encompass the most clinically relevant factors; however, some could be too complex for interdisciplinary clinical practice and do not adequately address unique entities, such as PS of the cervical spine, anterolisthesis and retrolisthesis. Most importantly, some criteria must be utilized in concert with recently published guidelines and should be re-assessed for validity and reliability. Auniform orthopedic parlance is required to optimize the management of this debilitating and life-threatening condition.

2.2 SIMPLIFYING SOMATIZATION: REDUCING HEALTH CARE UTILIZATION WITH A CLINICAL PRACTICE GUIDELINE FOR PEDIATRIC SOMATIC SYMPTOM AND RELATED DISORDERS

Somatic symptom and related disorders (SSRDs) are common yet complex conditions in pediatric medicine that can result in significant loss of functionality, poor quality of life, and high health care costs and utilization. This study describes the outcomes of an interdisciplinary clinical practice guideline (CPG) for the evaluation and management of pediatric SSRDs in an academic children’s hospital. Specific outcome measures include hospital cost, time to mental health consultation, length of stay (LOS), and readmission rates.

Interventional Oncology in Hepatocellular Carcinoma: Progress Through Innovation.

The clinical management of hepatocellular carcinoma has evolved greatly in the last decade mostly through recent technical innovations. In particular, the application of cutting-edge image guidance has led to minimally invasive solutions for complex clinical problems and rapid advances in the field of interventional oncology. Many image-guided therapies, such as transarterial chemoembolization and radiofrequency ablation, have meanwhile been fully integrated into interdisciplinary clinical practice, whereas others are currently being investigated. This review summarizes and evaluates the most relevant completed and ongoing clinical trials, provides a synopsis of recent innovations in the field of intraprocedural imaging and tumor response assessment, and offers an outlook on new technologies, such as radiopaque embolic materials. In addition, combination therapies consisting of locoregional therapies and systemic molecular targeted agents (e.g., sorafenib) remain of major interest to the field and are also discussed. Finally, we address the many substantial advances in immune response pathways that have been related to the systemic effects of locoregional therapies. Knowledge of these new developments is crucial as they continue to shape the future of cancer treatment, further establishing interventional oncology along with surgical, medical, and radiation oncology as the fourth pillar of cancer care.

Increased Reach of Genetic Cancer Risk Assessment as a Tool for Precision Management of Hereditary Breast Cancer.

Genetic cancer risk assessment (GCRA) is an interdisciplinary clinical practice that incorporates genetics, oncology, and counseling skills to quantify risk and implementmore precise care for individualswith inheritedcancerpredisposition.1GCRA is warranted for individuals with features suggesting hereditary cancer, such as early age at onset, triple-negative breast cancer, and/or a family history of breast or ovarian cancer. The cloning of theBRCA1 gene on chromosome 17 in 1994, and of a second high-risk locus (BRCA2) on chromosome 13 in 1995, ushered in an erawith increasing appreciation of the potential for oncogenetics to influence breast cancer screening, treatment, andprevention.Thesubsequentdecadeshavebeen marked by an ever greater understanding of gene-specific pathology and age-specific risk for BRCA-associated breast cancers, as well as a growing understanding of hormonal and genetic modifiers of risk.1 Commercial testing for BRCA1 and BRCA2 became available in theUnitedStates in1996,andprofessional societypolicy statements and practice guidelines affirm the value of BRCA testing for identifyingandmanaginghigh-risk individuals and families.2,3 In this issue, Rosenberg and colleagues4 describe BRCA gene testing and surgical decision-making outcomes amongparticipants in theYoungWomen’sBreastCancerStudy (YWS), amulticentercohortofwomen40yearsoryoungerwho had limited-stage breast cancer (ie, stage 0-II) and received GCRA at academic and community clinics between 2006 and 2014.Participantsweremostlywhite,well educated (85%completed college and/or graduate school), and virtually all had health insurance. One positive finding of the study was a relatively robust reach, in that most of the YWS study participants (87%) received BRCA gene testing within 1 year of their breast cancer diagnosis. While concerns have been expressed about proposed population-based BRCA testing for unaffected young women,5 we are heartened by the increasing participation in standard-of-care GCRA by young women with breast cancer. We concur with the authors4 that, unfortunately, it is unlikely that this level of access to, or participation in, GCRA would be found in the community setting or among the economically underserved or ethnic minorities. It is disconcerting that 48% of thosewho did not get testing indicated that they and/or their physician did not think a BRCA mutation was likely, despite the fact that the National Comprehensive Cancer Network (NCCN) guideline2 has recommended genetic counseling and BRCA testing for women with breast cancer diagnosed at 40 years or younger since the outset of the YWS study. The study results did not identify addeddistressasa reasonfordecliningBRCA testingat the time of cancer diagnosis, but the authors2 suggest this as a potential factor, referencingprevious studies that examinedand reported on this finding. The authors2 note the need to explain the practical purpose for genetic testing at the time of a new breast cancer diagnosis and address patient concerns. These issues are most consistently addressed as an essential component of pretest counseling when conducted by clinicians with expertise in GCRA. Comprehensive GCRA also addresses the challengesof conveying complex,uncertainoruninformative test results in a way that reduces confusion and uncertainty about risk management decision-making. Only a few participants (15) indicated concerns about genetic discrimination as a reason they declined BRCA testing. While historically a barrier to genetic testing, additional protectionswith theGenetic Information andNondiscriminationActof2008and lackofevidenceofgeneticdiscrimination6 have reduced these concerns in recent years. There is also a broadening social awareness andacceptability of genetic testing for hereditary predisposition. Thiswasmost dramatically evidencedduring the latterportionof theYWSsampling frame, when in May 2013 actress and director Angelina Jolie announced that she carries a BRCA1 mutation and chose to undergo a bilateral risk reductionmastectomy (RRM) and reconstruction. This announcement generated considerable interest in testing, evidenced by a surge in uptake of GCRA services and testing noted in the YWS study and others in the United States and internationally.7,8 It is notable that most of themedia sound bites on Jolie’s announcement included her clear admonition that although bilateralmastectomywas the answer forher, it is not always the answer—aqualification that is consistent with the NCCN guideline classification of RRM as an option for BRCA carriers.2 The YWS study2 reported a high uptake of RRM (86%) among the women diagnosed as having a BRCA mutation. While the precise timing of genetic testing relative to treatment decision-making was not reported in the study, the authors2 suggest that because testing took place within 3 months of diagnosis formost, andwithin 1 year for all participants, it is likely thatBRCA statuswas available at the time of surgical decision-making in context of breast cancer treatment. This finding is consistent with those of previous studies9-11documentingahighrateofRRMamongwomenwith newlydiagnosedbreast cancer identified asBRCA carriers, including an international study12 that noted significant variaRelated article page 730 Opinion

Tverrprofesjonell klinisk praksis for helsefagstudenter som en del av den ordinære praksisperioden, En casestudie fra en akutt geriatrisk-, slag - og rehabiliteringsavdeling

&lt;p&gt;&lt;strong&gt;&lt;em&gt;Interdisciplinary Professional clinical practice for health sciences students as part of the regular work placement- a casestudy from an acute geriatric - stroke and rehabilitation department.&lt;/em&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;This study describes students' experiences of interdisciplinary clinical practice (ICP) in an emergency department of geriatrics, stroke and rehabilitation in Norway. The purpose of this study was to investigate whether ICP has contributed to the students' knowledge of their own and other professional' expertise and expanded understanding of patients' rehabilitation needs. 19 students; nursing, occupational therapist, physiotherapist and social worker students were represented in the study. A model with various learning activities was developed in collaboration between two university colleges and the department. ICP lasted two weeks during a regular practice period. Students' experiences were evaluated through focus group interviews. The study concludes that collaboration in patient situations is essential for the students awareness of each other's disciplines, expanded perspective on own subjects and the patients need of rehabilitation. The short length of stay in the department led to increased focus on interaction early in the patient care.&lt;/em&gt;&lt;em&gt;&lt;/em&gt;&lt;/p&gt;

Challenges and facilitators to nurse use of a guideline-based nursing information system: Recommendations for nurse executives

AimsThe aims of this study were to develop empirical data on how nurses used an evidenced-based nursing information system (NIS) and to identify challenges and facilitators to NIS adoption for nurse leaders. BackgroundThe NIS was part of the electronic health record with 200 evidence-based, interdisciplinary clinical practice guidelines from which clinicians selected to guide the patient's care. MethodsA purposeful sample of 12 randomly selected nurses in three units across two hospitals participated in scenario-testing. Sessions were audio-recorded, transcribed, content analyzed, and coded for themes. ResultsMajor themes emerged: computer placement in patient rooms; difficulty using NIS; documentation completeness; efficiency; time spent at the bedside; team communication; training; unintended consequences of workflow changes; perceived NIS value as challenge to adoption. ConclusionsNurse executives' opportunities to improve adoption include enhancing communication to/from front-line clinicians about the hospitals' goals, perceived NIS value at the bedside, and constructive feedback especially for patient care/safety and software functionality.

Standardization of Interdisciplinary Clinical Practice and Assessment in Stroke Rehabilitation

Medical practice has increasingly focused on providing evidence-based interventions. We describe a process to standardize the interdisciplinary assessment of patients presenting for rehabilitation after stroke in a single academic medical center. Multiple assessment tools and outcome measures were reviewed for validity, specificity for stroke population, ease of administration, and utility in research. Interdisciplinary participation in the review process facilitated compliance with new documentation requirements. Measurements were incorporated into the electronic medical record from which an interdisciplinary database was developed for research applications. Clinically, the electronic medical record documentation is accessible to all healthcare providers in our medical system. Objective data from the use of quantifiable outcome measures facilitates clinical decision-making, more appropriate goal setting, and provides opportunities to optimize the value of the care delivered. It creates opportunities for best practices in the rehabilitation of patients with stroke and contributes to the provision of cost-effective patient care. Quantifiable measures also result in improved patient and caregiver understanding of patient impairment and progress, and as we observed, increased patient motivation in therapies. From a research perspective, having an interdisciplinary database in place enhances opportunities for future collaborative and integrated clinical studies. We posit that broad implementation of the care strategy outlined, and the database resulting from it, will also facilitate multicenter clinical research opportunities which will ultimately benefit patients with stroke.

Das motorisch ungeschickte Kind

This article describes the motor development of normal healthy children from school-age through adolescence and summarizes the recently published interdisciplinary clinical practice guidelines for the definition, origin, diagnosis, assessment and intervention of developmental coordination disorder (DCD).

European Academy of Childhood Disability (EACD): Recommendations on the definition, diagnosis and intervention of developmental coordination disorder (pocket version) German–Swiss interdisciplinary clinical practice guideline S3‐standard according to the Association of the Scientific Medical Societies in Germany*

Pocket versionbDefinition, diagnosis, assessment, and intervention of developmental coordination disorder (DCD) Rainer Blank (Chair of the Scientific Committee of the EACD, Task Force ‘Recommendations’). Hans Forssberg (Chair of the EACD). The recommendations were approved by a European panel of experts at the EACD meeting in Brussels, 26 May 2010, and through further DELPHI rounds. J M Albaret (France), A Barnett (United Kingdom), R Geuze (the Netherlands), D Green (Israel/United Kingdom), M Hadders-Algra (the Netherlands), S Henderson (United Kingdom), M L Kaiser (Switzerland), A Kirby (United Kingdom), R P Lingam (United Kingdom), H Polatajko (Canada), M Schoemaker (the Netherlands), B Smits-Engelsman (the Netherlands), H van Waelvelde (Belgium), P Wilson (Australia), S Zoia (Italy) (alphabetical order). Prof Dr Med Rainer Blank, University of Heidelberg, Child Centre Maulbronn, D-75433 Maulbronn, Germany. E-mail: [email protected]. ‘Underlying mechanisms’: P Wilson (Australia). ‘Consequences’, ‘Comorbidity’, ‘Definition and assessment’: R Blank (Germany). ‘Treatment’: B Smits-Engelsman (the Netherlands). H Becker (Germany), R Blank (Germany), O Jenni (Switzerland), M Linder-Lucht (Germany), H Polatajko (Canada), F Steiner (Switzerland), R Geuze (the Netherlands), B Smits-Engelsman (the Netherlands), P Wilson (Australia). The full guideline process was consistently advised by international experts in the field: B Smits-Engelsman (Physiotherapist, the Netherlands). H Polatajko (Occupational therapist, Canada). P Wilson (Neuropsychologist, Australia). R Geuze (Clinical physicist/neuropsychologist, the Netherlands). Recommendations (R) and statements (S) (according to algorithms). Definition, assessment, treatment indication (algorithm). Several recommendations are based on a formal consensus within a nominative group process, particularly those dealing with definition. Recommendations based on group consensus (GCP) are included in the guideline. A strong agreement (strong consensus ≥95%, if only ten or fewer participants were present ≥90% agreement) is marked as GCP ++; a moderate agreement (consensus ≥75–95%, if only ten or fewer participants were present ≥90%) is marked as GCP+.

Incorporating Goals-of-Care Conversations Into Hospital Admissions at a System-Wide Level: Policy and Educational Strategies (306)

1.Discuss the evidence for the emerging quality standard of care for assessing patient goals of care on admission to the hospital unit and matching patient goals with the care plan.2.Identify an approach for efficiently and accurately assessing patient goals with two novel communication strategies: one for patients admitted without an expected alteration in prognosis and the other for those admitted with life-threatening or prognosis-changing conditions. Tools will be provided to help participants teach these skills in their own settings.3.Discuss how to develop in your own settings a novel system-wide approach to meeting the quality standard with a coordinated approach using policy, admission order sets, electronic medical record reminders and education with both online and in-person learning modules and video clips. Patient-centered, cost-effective medical care is at the core of our daily work. Quality standards emerging from Europe promote the assessment of patient goals of care within 12–24 hours of admission to the intensive care unit. Patient goals are then matched to appropriate beneficial care. The growth of hospitalist medicine, the advent of rapid response teams on hospital wards, and the need to provide care that maximizes patient benefit for resources used, means the need for early goals assessment and the level of care documentation on admission to the hospital is ever pressing. Yet few health centers have a reliable system for this process. This session reviews the literature evidence for this emerging quality standard of care. Then through case presentations discussion simulation and video clips spanning 10 years of interdisciplinary clinical practice and teaching presenters will introduce two strategies for patient goals assessment. One strategy, the three-step “SAM” discussion, is for non-emergent patients without life-threatening illness and no expected change in prognosis. The second strategy, the five-step “UFO-UFO” discussion, is for selected non-emergent patients with life-threatening illness or expected change in prognosis. Each tool facilitates patient- and family-centered conversations consistent with recommendations in critical care and palliative care literature. Finally the session will share the experience of one six-hospital health system with a concerted system-wide intervention to bring system practice in line with this quality standard. The strategy and tips for policy and admission order development will be presented. The session will provide copies of the policy and admission order set and an overview of the SAM- and UFO-UFO–based system-wide online educational interventions. Presenters will share teaching tools and presentation guides for those wishing to share this information policy and skills approach to meeting the standard. Structure and Processes of Care

AMDA Takes the Lead on Pressure Ulcer Education

AMDA is preparing to introduce the long-awaited update of its pressure ulcer guideline. It has been a “daunting but incredibly rewarding task,” to take the 1996 original Pressure Ulcer guideline and the 1999 Pressure Ulcer Therapy Companion, and combine them into the new interdisciplinary clinical practice guideline, stated the American Medical Directors Association.The evidence-based, updated guideline, “Pressure Ulcer Prevention and Management in the Long Term Care Setting,” covers the revised federal regulations on pressure ulcers and updates staging, according to the 2007 National Pressure Ulcer Advisory Panel (www.npuap.org). It also discusses unavoidability; distinguishes pressure ulcers from venous, arterial, diabetic, and ischemic ulcers; and removes practices that were experientially based.In addition, there will be a session at the AMDA Annual Symposium on March 7, 2008, entitled “An Update on the Clinical Practice Guideline for Pressure Ulcers in the LTC Setting,” to update the essential components of the prevention and management of pressure ulcers in LTC institutions. Most important, it will cover updates that have occurred since publication of the last guidelines. A second session, “Advanced Technology in Wound Care: An Evidence-Based Review for Treatment of Nonhealing Ulcers,” will be presented the same day.In the meantime, resources on pressure ulcer detection and treatment can be found on the Clinical Corner dedicated to the topic at www.amda.com/tools/clinical/pressureulcers.cfm.Ms. Vance is the director of clinical affairs at the American Medical Directors Association. AMDA is preparing to introduce the long-awaited update of its pressure ulcer guideline. It has been a “daunting but incredibly rewarding task,” to take the 1996 original Pressure Ulcer guideline and the 1999 Pressure Ulcer Therapy Companion, and combine them into the new interdisciplinary clinical practice guideline, stated the American Medical Directors Association. The evidence-based, updated guideline, “Pressure Ulcer Prevention and Management in the Long Term Care Setting,” covers the revised federal regulations on pressure ulcers and updates staging, according to the 2007 National Pressure Ulcer Advisory Panel (www.npuap.org). It also discusses unavoidability; distinguishes pressure ulcers from venous, arterial, diabetic, and ischemic ulcers; and removes practices that were experientially based. In addition, there will be a session at the AMDA Annual Symposium on March 7, 2008, entitled “An Update on the Clinical Practice Guideline for Pressure Ulcers in the LTC Setting,” to update the essential components of the prevention and management of pressure ulcers in LTC institutions. Most important, it will cover updates that have occurred since publication of the last guidelines. A second session, “Advanced Technology in Wound Care: An Evidence-Based Review for Treatment of Nonhealing Ulcers,” will be presented the same day. In the meantime, resources on pressure ulcer detection and treatment can be found on the Clinical Corner dedicated to the topic at www.amda.com/tools/clinical/pressureulcers.cfm. Ms. Vance is the director of clinical affairs at the American Medical Directors Association.