Interdisciplinary Meetings Research Articles

200. Preventing surgical site hematoma with intravenous and topical tranexamic acid in lumbosacral surgery in a community teaching hospital: a resident-driven quality improvement project

<h3>BACKGROUND CONTEXT</h3> Postoperative hematoma following lumbosacral surgery carries significant morbidity. Tranexamic acid (TXA) has been shown to mitigate perioperative blood loss in lumbosacral fusion. <h3>PURPOSE</h3> We sought to report a quality improvement (QI) protocol using intravenous (iv) and/or tTXA to reduce postoperative surgical site hematoma (SSH) in patients undergoing elective lumbosacral surgery. <h3>STUDY DESIGN/SETTING</h3> Longitudinal comparative cohort. <h3>PATIENT SAMPLE</h3> Consecutive adults who underwent elective lumbosacral laminectomy and/or fusion in a single institution. <h3>OUTCOME MEASURES</h3> SSH hematoma necessitating evacuation of hematoma or readmission to the hospital due to hematoma. <h3>METHODS</h3> The FADE model was used. A feasibility study was performed in 2019 using IV or tTXA. Retrospective chart review demonstrated preimplementation baseline (7/1/18-6/30/19) SSH rate. Multiple interdisciplinary meetings were conducted to ensure standardized coagulopathy screening, TXA administration, drug supply, and compliance monitoring. Topical TXA was given in 2 g/250 NS via 60mL bulb syringe while ivTXA was given as 1 g bolus over 10 minutes. The QI project was integrated with the residents' patient safety activity. The QI start date was February 2020 with the interim analysis set for June 2020. The primary outcome was postoperative hematoma necessitating evacuation or hospital readmission. The secondary outcome was hospital length of stay. The post-implementation data were collected prospectively. A final analysis was performed for July 2020 - October 2020. Univariate analysis was used to compare outcome measures between pre- and postimplementation populations. A p-value < .05 was considered significant. A sample size calculation determined that there should be 198 patients in each group for a total of 396 patients. <h3>RESULTS</h3> During interim analyses, we found inadequate compliance with tTXA usage (68.5%). Stakeholders were reeducated regarding usage of tTXA and the implementation date was redefined as 7/1/2020. Comparing consecutive lumbosacral surgical patients in pre- (219 patients) and postimplementation (258 patients), the postimplementation group demonstrated significantly reduced incidence of SSH requiring evacuation (.38% vs 3.3%, p<.001) TXA compliance significantly improved after QI implementation (86.8% vs 9.6%, p=.001). The postimplementation tTXA group demonstrated that our standardized protocol resulted in a significantly lower incidence of SSH (.45% vs 4.8%, p=.004). <h3>CONCLUSIONS</h3> Our QI project demonstrated that the use of IV and tTXA was associated with a significantly lower rate of SSH requiring evacuation. We also demonstrated that the use of standardized administration of tTXA was associated with similar benefits when compared with nonstandardized tTXA administration. <h3>FDA DEVICE/DRUG STATUS</h3> tranexamic acid (Investigational/Not Approved)

Smoking-related interstitial lung diseases

Klinisches ProblemRaucherassoziierte interstitielle Lungenerkrankungen umfassen heterogene pulmonale Pathologien, deren korrekte Diagnostik prognostische und therapeutische Konsequenzen hat. In diesem Artikel werden die gängigsten raucherassoziierten interstitiellen Lungenerkrankungen beschrieben sowie eine strukturierte Herangehensweise präsentiert, welche den diagnostischen Arbeitsprozess erleichtern kann.Empfehlungen für die PraxisDie Computertomographie (CT) besitzt einen hohen Stellenwert in der Diagnose der raucherassoziierten interstitiellen Lungenerkrankungen und kann dazu beitragen, Lungenbiopsien zu verhindern. Um eine hohe diagnostische Genauigkeit zu erreichen, sollten standardisierte Untersuchungsprotokolle sowie eine strukturierte Herangehensweise in der Befundung zur Anwendung kommen. In den entzündlich dominierten Stadien der respiratorischen Bronchiolitis (RB), der respiratorischen Bronchiolitis mit interstitieller Lungenerkrankung (RB-ILD) sowie der desquamativen interstitiellen Pneumonie (DIP) haben die Beendigung des Rauchens sowie Steroide den größten therapeutischen Effekt. Bei fibrotischen Veränderungen (z. B. im Rahmen einer idiopathischen pulmonalen Fibrose [IPF]) können antifibrotische Therapien mit Pirfenidon und Nintedanib zum Einsatz kommen. Patienten mit dem Verdacht auf raucherassoziierte interstitielle Lungenerkrankung sollten in multidisziplinären Boards abgeklärt und behandelt werden.

Referring patients with suspected lung cancer: a qualitative study with primary healthcare professionals in Ireland.

Lung cancer is the leading cause of cancer death globally. Most cases are diagnosed late. Primary healthcare professionals are often the first point of contact for symptoms of concern. This study explored primary healthcare professionals’ experience of referring individuals with signs and symptoms suggestive of lung cancer along the appropriate healthcare pathway and explored strategies to help primary healthcare professionals detect lung cancer early. Focus groups and individual interviews were conducted with 36 general practitioners, community pharmacists, practice nurses, and public health nurses. Data were analysed thematically. Participants identified typical lung cancer signs and symptoms such as cough and coughing up blood (i.e., haemoptysis) as triggers for referral. Atypical/non-specific signs and symptoms such as back pain, pallor, and abnormal blood tests were perceived as difficult to interpret. Participants often refrained from using the word ‘cancer’ during conversations with patients. Ireland’s Rapid Access Lung Clinics were perceived as underused, with some general practitioners referring patients to these clinics only when clear and definitive lung cancer signs and symptoms are noted. Lack of communication and the resulting disruption in continuity of care for patients with suspected lung cancer were highlighted as healthcare system flaws. Education on early referral can be in the form of communications from professional organizations, webinars, interdisciplinary meetings, education by lung specialists, and patient testimonials. Lung cancer referral checklists and algorithms should be simple, clear, and visually appealing, either developed as standalone tools or embedded into existing primary care software/programmes.

Applying Lean Kaizen to improve timely CT scan appointments for oncology patients in a safety-net hospital.

e18627 Background: Timely radiographic studies are essential to oncology care. At our institution, a safety net hospital in a large metropolitan area, baseline assessment determined that the overwhelming majority of outpatient computed tomographic (CT) scans for oncology patients were overdue for scheduling. We applied the Lean Kaizen quality improvement model to improve on-time scheduling of CT scans in our hematology-oncology clinic. Lean Kaizen is centered around eliminating waste, improving productivity, and maintaining sustained improvement through collaborative efforts from multiple departments to analyze system workflow inefficiencies in a stepwise fashion. Methods: In collaboration with our Kaizen Promotion Office, we conducted a series of interdisciplinary meetings including staff from radiology, oncology, scheduling, and administration. All aspects of the scheduling workflow were critically reviewed and barriers to scheduling were identified using an Ishikawa root-cause diagram and the Kaizen principle of gemba (“go and see the work”). A new workflow was developed in which clinic staff scheduled patients for CT scans prior to clinic discharge. To implement the new workflow, we employed the principles of shojinka (“create flow”) and nagara (“eliminate waste”). We developed and distributed workflow guides, conducted simulation events, and provided one-on-one training to ensure a successful rollout. Three months after our initial meeting, the new workflow was launched. The workflow was refined based on feedback from daily pre-clinic team meetings. Results: Preliminary data were gathered approximately 3 weeks following implementation of our new workflow. Since our intervention, the percentage of CT scans overdue for scheduling decreased from 87% (65 of 75 CT scans) to 17% (9 of 53 CT scans). Conclusions: Our study showed that the Lean Kaizen QI model was successful in improving the rate of oncology patients scheduled for CT scans in a timely fashion. This study demonstrated the importance of interdepartmental collaboration and continuous monitoring for improvement. Given the success of this project, this workflow will be expanded to other services within our institution following the Kaizen principle of yokoten (“sharing knowledge”).

Strengthening Communication and Collaboration in the Fragmented German Healthcare System: A Mixed-Method Evaluation of an Interdisciplinary Network for Parkinson’s Disease

To improve Parkinson's disease (PD) care, interdisciplinary and patient-centered treatment is mandatory. A key problem in many healthcare systems is the limited and unspecific communication among different healthcare professionals. Optimal collaboration between various professionals involved is indispensable. Parkinson's Network Münsterland + (PNM +) is an interdisciplinary network of medical and non-medical experts involved in the treatment of PD patients in Germany. The aim of this evaluation was to analyze the network structures of PNM+ as well as communication and collaboration between PNM + partners. A mixed methods approach was applied consisting of a social network analysis, a validated questionnaire on team effectiveness and semi-structured interviews focusing on perceived barriers and supportive aspects of PNM + . Quantitative and qualitative data suggested increased collaboration between professionals within PNM + . The reciprocity of connections was 0.522 in the network of professional contacts. Regular exchanges in terms of interdisciplinary panel meetings and working groups stimulated knowledge transfer, leading to greater specialization of general neurologists and therapists in PD. The progressive density of the network from 0.136 to 0.279 illustrates the growing cooperation of PNM + partners. Interviewed partners requested more patient-specific collaboration but expected this to happen as the network evolved. Overall, PNM + has already improved both diagnosis and therapy thanks to knowledge transfer. Structured treatment recommendations helped to improve communication between healthcare professionals. PNM+ stimulated exchange between different healthcare professionals involved in the treatment of PD patients. This overcomes specific barriers within Germany's highly fragmented healthcare system, such as the lack of communication between these disciplines.

Precision Medicine in Inflammatory Bowel Diseases: Challenges and Considerations for the Path Forward

Precision Medicine in Inflammatory Bowel Diseases: Challenges and Considerations for the Path Forward

The Lived Experience of Physical Separation for Hospice Patients and Families amid COVID-19

ContextMany hospice patients were physically separated from family members and healthcare professionals during the early COVID-19 pandemic. ObjectivesResearchers sought to describe the lived experience of physical separation for hospice patients and family caregivers who adhered to public health guidelines intended to limit the transmission of COVID-19 in the spring of 2020. MethodsResearchers performed a secondary analysis of qualitative data collected during a multi-site clinical trial of an intervention that incorporated family caregivers into care plan reviews during biweekly hospice interdisciplinary team meetings. Twenty-eight adult family caregivers of hospice patients with cancer participated in at least one care plan review between March 7, 2020 and June 10, 2020. The final analytic dataset included the transcribed content of 60 care plan reviews, which were analyzed via reflexive thematic analysis. ResultsHospice patients and their family caregivers experienced physical separation as interrupted care that resulted in the potential for unmet informational, functional, and social and emotional needs. Connection strategies employed to adapt to care interruptions and address patient and caregiver needs were not consistently effective. ConclusionInclusive, innovative connection strategies are needed to ensure that high-quality end-of-life care is provided to hospice patients and their family caregivers when physical presence must be limited.

Quality of care assessment for small and sick newborns and young infants in Pakistan: findings from a cross-sectional study

IntroductionPakistan is facing a challenging situation in terms of high newborn mortality rate. Securing pregnancy and delivery care may not bring a substantial reduction in neonatal mortality, unless coupled with the provision of quality inpatient care for small and sick newborns and young infants (NYIs). We undertook this study to assess the availability and quality of newborn care services provided and the readiness of inpatient care for NYIs in Pakistan.MethodsWe conducted a cross-sectional study across Pakistan from February to June 2019, using a purposive sample of 61% (23) of the 38 sick newborn care units at public sector health care facilities providing inpatient care for small and sick NYIs. We interviewed facility managers and health care providers by using structured questionnaires. We observed facility infrastructure and relevant metrics related to the quality of inpatient care such as types of infant care units and essential equipment, drugs, staffing cadre and facility management practices, quality assurance activities, essential services for small and sick NYI care, discharge planning, and support, quality of NYIs care record, and health information system.ResultsOf the 23 facilities assessed, 83% had newborn intensive care units (NICUs), 74% reported Special Care Units (SCUs), and only 44% had Kangaroo Mother Care (KMC) Units. All facilities had at least one paediatrician, 13% had neonatologists and neonatal surgeons each. Around 61 and 13% of the facilities had staff trained in neonatal resuscitation and parental counseling, respectively. About 35% of the facilities monitored nosocomial infection rates, with management and interdisciplinary team meetings reported from 17 and 30% of the facilities respectively preceding the survey. Basic interventions for NYIs were available in 43% of the facilities, only 35% of facilities had system in place to monitor nosocomial infections for NYI care. Most (73%) of reviewed records of NYIs at 1–2 days had information on the birth weight, temperature recording (52%), while only a quarter (25%) of the observed records documented danger signs. Mechanism to support discharge care by having linkages with community workers was present in 13% of the facilities, while only 35% of the facilities have strategies to promote adherence after discharge. Majority (78%) of facilities reported monitoring any newborn/ neonatal care indicators, while none of the sub-units within facilities had consolidated information on stillbirths and neonatal deaths.ConclusionThe study has demonstrated important gaps in the quality of small and sick NYI inpatient care in the country. To avert neonatal mortality in the country, provincial and district governments have to take actions in improving the quality of inpatient care.

Turning the Lens Inward: The Psychological Elements of Clinician Well Being.

This is the seventh entry in the Psychological Elements of Palliative Care (PEPC) series. Previous articles have focused on the psychological elements of the care we provide patients and the relationships we build with our referring clinician colleagues. In this entry, we focus on how the PEPC also impact clinician well being. The PEPC are bidirectional: we impact patients, but patients also impact us. The reactions that we have to patients and the boundaries we set around the care we provide are two examples of psychological factors of care that can influence our well being. Creating spaces to explore and reflect on the psychological impact of the clinical care we provide is a key component of wellness. Such spaces vary in their configuration, but all share the opportunity to self-reflect and to experience emotional validation, normalization, and reality testing from peers or mentors. In mental health training, clinical supervision is one common format for creating such a space. While this can be replicated in the palliative care setting, other strategies include integrating a psychological orientation into interdisciplinary team meetings, creating peer support or process groups, and creating small groups within teams for longitudinal self-reflection.

The implementation of post breast cancer surgery physical therapy instructions for patients―A case study of Israeli medical centers

That patients undergoing breast cancer (BC) surgery need instruction post-surgery has been well described in the literature. Therefore, new off and online patient instructions have been developed and made available in Israel. This study aimed to evaluate the degree to which these instructions reach patients in Israeli medical centers and reasons for use or non-use. A case study. The study population were managers of physical therapy services in Israeli medical centers. Telephone interviews, using a semi structured questionnaire, were recorded and transcribed. The research team summarized and discussed the issues raised. Managers of physical therapy service or representative from 18 public medical centers were interviewed. All medical centers employ a full or part time physical therapist in their surgical wards and all except one provide some pre-discharge instructions to all or to selected women after BC surgery. Nine interviewees think that the new instruction is suitable as is. Disagreeing opinions were that the content is too long and not suitable for all patients. In medical centers with strong interdisciplinary cooperation there is greater use of the new instruction. Online distribution of instruction to the managers of the PT services in medical centers helped encourage their use. Instruction promotion can be increased through interdisciplinary cooperation, educational seminars, staff meetings and electronic media.

Gaps and Opportunities to Improve Prevention of Human Papillomavirus-Related Cancers.

Human papillomavirus (HPV) infections cause more than 35,900 cancers annually in the United States. Although cervical cancer is the most prevalent HPV-related malignancy in women, the virus is also responsible for a significant percentage of anal, vaginal, and vulvar cancers. A comprehensive approach to mitigating cervical cancer includes HPV vaccination (primary prevention), screening and treatment of precancerous lesions (secondary prevention), and diagnosis and treatment of invasive cancer (tertiary prevention). Although a successful strategy, there are opportunities to innovate and increase access that can also be adapted to address the unique clinical care gaps that exist with the other anogenital cancers. The Society for Women's Health Research held a series of interdisciplinary meetings and events, during which expert researchers, clinicians, patient advocates, and health care policy leaders evaluated the current landscape of HPV-related cancers and their effects on women's health. This report summarizes the discussions of this working group and areas it identified in which to address gaps in primary and secondary prevention approaches to improve access and health outcomes for women with HPV-related anogenital cancers.

Mixed methods analysis of hospice staff perceptions and shared decision making practices in hospice.

Shared decision making has been a long-standing practice in oncology and, despite a lack of research on the subject, is a central part of the philosophical foundation of hospice. This mixed methods study examined the perceptions of staff regarding shared decision making and their use of shared decision elements in hospice interdisciplinary team meetings. The revised Leeds Attitude to Concordance scale (LatConII) was used to measure the attitudes of hospice staff toward shared decision making. Field notes and transcripts of hospice interdisciplinary team meetings that included family caregivers as participants were coded to identify 9 theory-driven shared decision making elements. The results were mixed in a matrix analysis comparing attitudes with practice. Three transcripts demonstrate the variance in the shared decision making process between hospice teams. Hospice staff reported overall positive views on shared decision making; however, these views differed depending on participants' age and position. The extent to which staff views were aligned with the observed use of shared decision making elements in hospice interdisciplinary team meetings varied. Policy and practice conditions can make shared decision making challenging during hospice interdisciplinary team meetings despite support for the process by staff. This study is a sub-study of a parent study registered with clinicaltrials.gov (NCT02929108).

Palliative care integration for patients with advanced chronic obstructive pulmonary disease (COPD): Identifying essential components using participatory action research

Background: Chronic obstructive pulmonary disease (COPD) is a life-limiting condition with palliative care needs. Despite increasing awareness about the role palliative care can play in care provision for patients with advanced COPD, integration in standard care remains underdeveloped. The unpredictability of the disease progression and misconceptions about palliative care being equivalent to end-of-life care often prevent a timely integrated approach in advanced COPD. Aim: To identify practices designed to increase integration of palliative care in the management of patients with advanced COPD in a respiratory service in Southern Switzerland. Design: A participatory action research approach was chosen and key stakeholders were involved to develop new knowledge and practices, supported by a Theory of Change framework. Data from each cycle and retrospective analysis at the end of the whole research were analysed using thematic analysis. Setting/participants: Five action research cycles with seven healthcare professionals working in palliative or respiratory care settings were conducted. Results: Three elements of integrated palliative care in advanced COPD were identified: multidimensional assessment, healthcare professionals’ education and interdisciplinary team meetings, which are the pillars of a new integrated palliative care model for patients with advanced COPD. Conclusions: The new integrated palliative care model in advanced COPD includes essential elements with a focus on patients, healthcare professionals and care delivery. Further research on testing this model in clinical practice, service development, implementation processes and possible outcomes, including evaluation of the financial impact of integrated palliative care is necessary to foster this care approach across all possible settings.

Lessons Learned from Transitioning to Telerehabilitation During COVID-19 in Alberta, Canada

Research ObjectivesTo better understand rehabilitation practitioner experiences with transitioning to telerehabilitation services during COVID-19, specifically around the use of technology and client assessment and treatment.DesignThis was a qualitative study of cross-sectional design. Rehabilitation practitioners completed semi-structured interviews via Zoom. Transcribed interviews were analyzed for themes.SettingWith the onset of COVID-19, rehabilitation practitioners quickly adapted and started offering telerehabilitation services where they interacted directly with the client and evaluate, diagnose, and treat their condition virtually. These services differed from prior methods of telehealth, where healthcare practitioners delivered care from one healthcare facility to another. Practitioners from both public and private clinics shifted their services to virtual platforms quickly to provide continued care to patients needing acute and prolonged rehabilitation care.ParticipantsTwenty-four rehabilitation practitioners were recruited to participate in the study (14 physiotherapists, 4 occupational therapists, 2 speech language pathologists, 1 psychologist, 1 kinesiologist, 1 social worker, 1 orthopedic surgeon) from rural and urban clinics as well as private and publicly funded practices. Inclusion criteria required practitioners to have transitioned to telerehabilitation, either through video conferencing or telephone.InterventionsN/A.Main Outcome MeasuresN/A.ResultsThe overarching theme which emerged from the data was providing continued access to care. Rehabilitation practitioners quickly transitioned to using the telephone or video conferencing platforms such as Zoom to connect with clients. Multiple subthemes emerged allowing for a better understanding of the transition to telerehabilitation during COVID-19. Barriers to offering telerehabilitation services included adequate access to technology (computer, laptop, tablet) and IT support for the client and sufficient internet bandwidth. Limited availability of validated virtual assessments made the transition difficult for practitioners. However, many benefits emerged such as easier scheduling of interdisciplinary meetings, increased client accountability, better access to group programming, and decreased travel times to clinics.ConclusionsAlthough there were challenges, especially surrounding technology, the switch to telerehabilitation had many benefits and could be a viable method of delivering care that goes beyond the COVID-19 pandemic.Author(s) DisclosuresAuthors have no conflicts of interest to disclose.

Quality of inpatient care of small and sick newborns in Pakistan: perceptions of key stakeholders

BackgroundIn LMICs including Pakistan, neonatal health and survival is a critical challenge, and therefore improving the quality of facility-based newborn care services is instrumental in averting newborn mortality. This paper presents the perceptions of the key stakeholders in the public sector to explore factors influencing the care of small and sick newborns and young infants in inpatient care settings across Pakistan.MethodsThis exploratory study was part of a larger study assessing the situation of newborn and young infant in-patient care provided across all four provinces and administrative regions of Pakistan. We conducted 43 interviews. Thirty interviews were conducted with the public sector health care providers involved in newborn and young infant care and 13 interviews were carried out with health planners and managers working at the provincial level. A semi-structured interview guide was used to explore participants’ perspectives on enablers and barriers to the quality of care provided to small and sick newborns at the facility level. The interviews were manually analyzed using thematic content analysis.FindingsThe study respondents identified multiple barriers contributing to the poor quality of small and sick newborn care at inpatient care settings. This includes an absence of neonatal care standards, inadequate infrastructure and equipment for the care of small and sick newborns, deficient workforce for neonatal case management, inadequate thermal care management for newborns, inadequate referral system, absence of multidisciplinary approach in neonatal case management and need to institute strong monitoring system to prevent neonatal deaths and stillbirths. The only potential enabling factor was the improved federal and provincial oversight for reproductive, maternal, and newborn care.ConclusionThis qualitative study was insightful in identifying the challenges that influence the quality of inpatient care for small and sick newborns and the resources needed to fix these. There is a need to equip Sick Newborn Care Units with needed supplies, equipment and medicines, deployment of specialist staff, strengthening of in-service training and staff supervision, liaison with the neonatal experts in customizing neonatal care guidelines for inpatient care settings and to inculcate the culture for inter-disciplinary team meetings at inpatient care settings across the country.

La pandemia nei sogni

The pandemic within dreams. The article aims to analyse different representations of the pandemic within dreams to trace correspondences between the symbolic expressions of the oneiric language and the sociology of the imaginary. The theoretical-methodological framework of Carl G. Jung and Marie-Louise von Franz guides the articulation of the essay. The unconscious lived through the memory of dreams has the typical and strong tendency to be projected externally, hence the hypothesis that it is possible to grasp its reflections in external reality and the social world. The question to be answered concerns which shared movements are present in the unconscious of individual subjects during the current period dominated by the pandemic and which relationships can be detected between the symbolic material emerging in individual dreams and some contemporary cultural phenomena. The empirical material is drawn from a series of interdisciplinary meetings regarding patients' dreams during the pandemic.

Targeted Program in an Academic Rheumatology Practice to Improve Compliance With Opioid Prescribing Guidelines for the Treatment of Chronic Pain.

The Centers for Disease Control and Prevention (CDC) and many state governments have issued guidelines for opioid prescribing for the treatment of chronic noncancer-associated pain. We sought to decrease practice variation and increase compliance with these guidelines in a tertiary academic rheumatology practice by developing an interdisciplinary opioid working group and using electronic health record (EHR)-integrated data feedback. Division leadership and providers established shared goals at interdisciplinary meetings involving rheumatology, pain medicine, nursing, and pharmacy. Interventions included educational sessions on opioid prescribing guidelines and the sharing of individual de-identified prescribing patterns. An opioid dashboard page within the EHR allowed every provider to see individualized and division-wide data that tracked process measures based on CDC and state-specific guidelines. Baseline data from June to August 2017 were compared with monthly data through December 2018. At baseline, 40% of patients had an active opioid agreement (a Pennsylvania guideline and a New Jersey law), 25% had a urine drug screen result within 12 months of their most recent opioid prescription, and 24% had a concurrent benzodiazepine prescription. After 16 months, these percentages improved to 88%, 66%, and 16%, respectively. The average number of opioid tablets prescribed per month decreased from 59,733 to 48,966 (-18%; P = 0.02). Shared goals developed through interdisciplinary input and readily accessible data feedback can markedly increase provider compliance with national and state-specific guidelines for opioid prescribing for the treatment of chronic noncancer-associated pain in rheumatology.

An Overview of Online Resources for Medical Spanish Education for Effective Communication with Spanish-Speaking Patients

Phenomenon Despite the rapid development of virtual medical Spanish educational materials, online resources lack transparency and a peer-review process. The purpose of this interdisciplinary study was to provide a critical inventory of virtual resources for medical Spanish education, thereby providing a panorama of the current state of online medical Spanish. Approach Research team members conducted iterative searches to identify medical Spanish online resources, which were then screened for predetermined inclusion/exclusion criteria. Between June and August 2020, a panel of medical and language experts then adapted and applied a previously published evaluation tool to determine whether resources that met study criteria would help learners achieve medical Spanish core competencies and to what extent each resource incorporated communicative language activities. Consensus meetings were conducted to resolve disagreements and identify gaps in online education. Findings Out of 465 resources, 127 were further screened, and eight were selected for evaluation. Medical and language specialists independently scored each resource and, following discussions, achieved consensus. Overall, no resource met suitability criteria for all five medical Spanish learner competencies or cultural elements, and only one was suitable for achieving the self-assessment competency. Insights Interdisciplinary consensus meetings provide an important avenue for resolving differences of opinion and for integrating both language and medical perspectives into the evaluation process. Existing online resources should be used in conjunction with other materials to ensure that all core competencies for medical Spanish education are addressed. This study revealed important gaps in online resources, including a need to target advanced Spanish learners, apply authentic communicative activities, include assessment opportunities, and integrate culture in the learning program. Based on the current state of online medical Spanish, we offer recommendations for future resources.

Transition of Care Model for Pediatric Patients With Nonalcoholic Fatty Liver Disease.

Transition of Care Model for Pediatric Patients With Nonalcoholic Fatty Liver Disease.

Applying the Care and Communication Bundle to Promote Palliative Care in a Neuro-Intensive Care Unit: Why and How.

Background: Delivery of palliative care in neurointensive care units (neuro-ICUs) can be inconsistent, often due to absence of formal care triggers. The Care and Communication Bundle (CCB) of Quality Indicators provides a standardized process to deliver effective palliative care services in ICUs, but application of these indicators in this setting has not yet been systemically assessed. Objectives: To evaluate the fit of a CCB in the neuro-ICU through a novel scoring system and identify barriers to adherence. Design: CCB standards for a neuro-ICU were delineated. Assessment of documented indicators and barriers was conducted through electronic medical record retrospective review. Setting/Subjects: A 30-bed neuro-ICU in a large Academic Medical Center in the Southeastern United States. Chart reviews were conducted for 133 critically ill neurology and neurosurgery patients who expired between November 2018 and January 2020. Results: Results demonstrate moderate adherence to CCB standards, including excellent consistency in establishment of patient-centered communication and referral to supportive services (e.g., social work, spiritual support). Identified areas for improvement include documentation of patient and family involvement in care process (i.e., advance directive completion, interdisciplinary team meetings). Conclusions: Application of the CCB in the neuro-ICU is useful for examining adherence to time-based triggers of palliative care standards. The novel scoring system offers opportunities to motivate improvement and reduce variation in palliative care integration.