Managing Complex Cases Research Articles

Complexity of comprehensive care treatments in undergraduate dental programs: The benefits of observing and assisting experienced faculty members.

ObjectiveTo improve the confidence of the final year dental students in completing occlusal and oral rehabilitation of patients, with complexities beyond their scope, based on full analysis of the biomechanical and esthetic considerations of each case.Material & methodsTwo comprehensive patient situations presenting with special difficulties including extensive, reduced vertical dimension of occlusion, limited interocclusal space and maxillary alveolar bone for implant insertion necessitating bone augmentation and a sinus lift surgery was managed by two students at our institute. Procedures like surgical crown lengthening, sinus lifting, and bone augmentation were performed by senior faculty with the respective two students’ assisting as well as following up at the healing phase and reporting progress of healing and any possible complications to the supervisor. Students’ reported significant improvement in decision making skills; time management; interpersonal skills, management of cases in an evidence –based interdisciplinary approach as well as increase in their confidence in managing complex cases independently. Follow up with both cases showed optimum outcome and patients’ satisfaction.ResultsStudents’ reported significant improvement in decision making skills; time management; interpersonal skills, management of cases in an evidence –based interdisciplinary approach as well as increase in their confidence in managing complex cases independently. Follow up with both cases showed optimum outcome and patients’ satisfaction.ConclusionsExposing students to manage complex oral rehabilitation including procedures like sinus lifting and bone augmentation, through an evidence-based interdisciplinary approach during the undergraduate comprehensive clinical dentistry course enhances their confidence and clinical acumen as an independent practitioner.

Science, art and alchemy: best practice in facilitating restorative justice

This paper explores the role and process of facilitation in restorative justice (RJ). Drawing from a victim offender conferencing program used after serious crime in New South Wales Australia, 84 interviews with restorative facilitators were thematically analysed. The skills, techniques and strategies used to prepare, conduct and de-brief cases are considered including managing complex cases where participants present with intense anger and grief, poor insight into offending and cognitive and mental health issues. While good facilitation is in part the result of knowledge, training and experience, the art of great facilitation relates to the interplay of the facilitator’s inherent characteristics, capacities and world-views alongside this knowledge, skill and experience. While facilitating well is premised on an appreciation of the alchemy that exists within RJ, advanced facilitators use the alchemy to shape the process. Good practice is further enabled through workplace structures that support a team approach where there is open deliberation around needs, risk and harm. Because good facilitation is paramount to the best practice of RJ this paper has implications for current policy debates concerning RJ standards and the training and accreditation of RJ practitioners.

‘It's surprising how differently they treat you’: a qualitative analysis of trainee reflections on a new programme for generalist doctors

ObjectivesAn increase in patients with long-term conditions and complex care needs presents new challenges to healthcare providers around the developed world. In response, more broad-based training programmes have developed to...

North West Province Department of Health and BroadReach Healthcare Partnership Model

South Africa has the largest number of people living with HIV globally, and the world's largest antiretroviral therapy (ART) programme with over 2 million people estimated to have received ART by 2013 [2,3]. Recognizing the significant constraints on public sector resources to meet increasing public demand and need for ART initiation, BroadReach Healthcare and the North West Province Department of Health (DOH) implemented the private General Practitioner (GP) 'Down Referral' Model commencing in 2005 and ongoing, to provide HIV treatment and care for patients stable on ART. Implementation of this model leverages existing capacity within the private sector, shifting delivery of ART in stable patients from hospitals to lower-level private health facilities, and allowing public facilities to focus on initiating new ART eligible patients and managing complex cases. Over 10 years, the model has proved highly successful where the probability of patient survival at 12 and 48 months is 99% and 89% respectively, and retention at 48 months remains high at 94% [7]. This model is a simple, robust, evidence based and easily replicable model for rolling out a defined health service at scale, and further demonstrates potential for public private partnerships in addressing the burden of chronic disease.

Supporting novice clinicians cognitive strategies: System design perspective.

Infections occur among all clinical domains. The changing nature of microbes, viruses and infections poses a great threat to the overall well-being in medicine. Clinicians in the infectious disease (ID) domain deal with diagnostic as well as treatment uncertainty in their everyday practice. Our current health information technology (HIT) systems do not consider the level of clinician expertise into the system design process. Thus, information is presented to both novice and expert ID clinicians in identical ways. The purpose of this study was to identify the cognitive strategies novice ID clinicians use in managing complex cases to make better recommendations for system design. In the process, we interviewed 14 ID experts and asked them to give us a detailed description of how novice clinicians would have dealt with complex cases. From the interview transcripts, we identified four major themes that expert clinicians suggested about novices' cognitive strategies including: A) dealing with uncertainty, B) lack of higher macrocognition, C) oversimplification of problems through heuristics and D) dealing with peer pressure. Current and future innovative decision support tools embedded in the electronic health record that can match these cognitive strategies may hold the key to cognitively supporting novice clinicians. The results of this study may open up avenues for future research and suggest design directions for better healthcare systems.

Management of complex clinical issues

When dealing with complex clinical issues within the perioperative environment, effective management is crucial for ensuring a high standard of patient care. When carried out correctly, managing complex cases can rapidly reduce risks in the patients perioperative journey. An example of this will be explained in this reflective article.

Assessment of APRN Student Competency Using Simulation: A Pilot Study.

Assessment and evaluation of competency for advanced practice registered nurses (APRNs) is a challenge facing educators, regulators, and consumers of health care. The purpose of this study was to determine the effectiveness of using simulation to assess and evaluate APRN student competence in managing complex cases. Students were videotaped in the simulation laboratory at four separate intervals; two independent reviewers used the APRN Competency Evaluation Tool to review the simulation. Results showed statistically significant improvement in all categories of evaluation following increased exposure to simulation of complex cases. Student competence increased for managing complex patients, use of evidence-based guidelines, patient safety, leadership, prioritization, delegation, collaboration, communication, and professionalism.

Behavioral Health Training Is Good Medicine for Counseling Trainees: Two Curricular Experiences in Interprofessional Collaboration

Based on training efforts at two universities, this article explores considerations when mental health professionals (MHPs) are trained to work effectively in primary care settings. It first outlines the curriculum of an advanced doctoral level course in health psychology practice. To better refine the experiences of trainees, it then describes a qualitative pilot study of counseling psychology practicum students (N = 4) in a primary care setting. Six themes from the interviews and focus groups are identified: mental health culture, primary care context, challenging entry, adapting to the primary care context, managing complex cases, and results of the collaborative process. Finally, it provides recommendations for future training and research direction.

PARS PLANA AHMED VALVE AND VITRECTOMY IN PATIENTS WITH GLAUCOMA ASSOCIATED WITH POSTERIOR SEGMENT DISEASE

To assess the safety and efficacy of a modified technique for pars plana placement of the Ahmed valve in combination with pars plana vitrectomy in the treatment of glaucoma associated with posterior segment disease. Thirty-nine eyes with glaucoma associated with posterior segment disease underwent pars plana vitrectomy combined with Ahmed valve placement. All valves were placed in the pars plana using a modified technique, without the pars plana clip, and using a scleral patch graft. The 24 eyes diagnosed with neovascular glaucoma had an improvement in intraocular pressure from 37.6 mmHg to 13.8 mmHg and best-corrected visual acuity from 2.13 logarithm of minimum angle of resolution to 1.40 logarithm of minimum angle of resolution. Fifteen eyes diagnosed with steroid-induced glaucoma had an improvement in intraocular pressure from 27.9 mmHg to 14.1 mmHg and best-corrected visual acuity from 1.38 logarithm of minimum angle of resolution to 1.13 logarithm of minimum angle of resolution. Complications included four cases of cystic bleb formation and one case of choroidal detachment and explantation for hypotony. Ahmed valve placement through the pars plana during vitrectomy is an effective option for managing complex cases of glaucoma without the use of the pars plana clip.

Managing Common Complex Symptomatic Epilepsies: Tumors and Trauma

Head trauma and brain tumors are inextricably linked to epilepsy. Both traumatic brain injury and brain tumors are overrepresented in newly diagnosed patients with epilepsy, as well as in patients with drug-resistant focal epilepsy. Indeed, chronic seizures are the most cited problem associated with either of these conditions. However, managing complex cases of posttraumatic epilepsy or tumor-based epilepsy can be a challenge for many epilepsy specialists. Currently, there is no clear understanding of the basic science that underpins the mechanism for epileptogenesis in patients with tumors or trauma so at present one cannot identify appropriate targets that could help prevent seizures and epilepsy from occurring. Because of these challenges, complex lesional epilepsy was chosen as the theme for this year’s 2012 American Epilepsy Society Annual Course. The objectives for the course included understanding models for preventing epileptogenesis, creating best evidence algorithms that describe how to best manage patients with epilepsy related to brain tumors, including novel intraoperative monitoring techniques. Risk analyses were summarized to benefit treatment decisions regarding the prophylactic use of antiepileptic drugs in patients with CNS tumors or traumatic brain injury and to present the best management options with patients with metastatic brain tumors based on current knowledge. Throughout two half-day sessions, post-traumatic epilepsy and tumoral epilepsy were explored in detail. Each session was framed by clinical cases involving adults and children. Through a variety of learning methodologies that included lectures, debates, and panel sessions, clinical management was highlighted, illuminating basic science and practice gaps. This discussion summarizes the salient take-home points of the session that are clinically useful for the practicing clinician.

Management of iatrogenic full thickness electrical burn in a preterm neonate using W-plasty technique combined with a median sternotomy incision

Burns in the neonatal period are rare and most commonly due to iatrogenic causes. We report a case of a preterm neonate who sustained a full thickness electrical burn following the use of a temporary pacing pad. The case was complicated by significant co-morbidities and the need for cardiac surgery. We describe the surgical management of the case, using excision and closure in the form of a W-plasty. We discuss the reasons for this surgical decision and the importance of managing complex cases such as this on an individual basis.

The Meaning of Occupational Health among Human Resources Professionals—A Qualitative Study

The study findings provide clear rationale for employing occupational health nurses as specialists in understanding occupational health, particularly in the areas of information seeking (e.g., identifying health resources and best practices) and illness or disability management (e.g., managing complex cases and addressing psychosocial factors). Occupational health nurses can assist human resources professionals to direct their energies to administrative and cultural features within their organizations that impact the health of employees and that clearly fall within their realm of expertise (e.g., working to create a workplace climate of genuine concern for employees). Occupational health nurses can provide aggregate information on the health of the work force to strategically encourage, direct, and harness employer investments in workplace health. Finding ways to translate and communicate workplace health information so it is accessible and useable by employers to direct decision making is a key role for occupational health nurses.