Team Meetings Research Articles

OGC SO03 - Impact of recent European consensus guidelines on Oligometastic Disease (OMD) and potential case load of Oesophagogastric cancer resections

Abstract Background To evaluate the impact of recently devised oligometastatic disease (OMD) criteria as per the European consensus guidelines on the eligibility of Oesophagogastric (OG) cancer patients for curative treatment. Method A retrospective analysis was conducted on OG cancer cases discussed at multidisciplinary team (MDT) meetings at a tertiary university hospital from January 2018 to December 2023. Inclusion criteria included T2-T4a adenocarcinomas, T2-T4b squamous cell carcinomas, small cell carcinoma and adeno-squamous carcinomas that were classified as M1 disease. Exclusion criteria were T4b adenocarcinomas, M1 peritoneal disease, non-adeno/ squamous carcinoma histology, M1 peritoneal cytology, and head and neck squamous cell carcinomas proximal to the thoracic inlet. Data on patient demographics, T stage, histology, and metastatic sites were analysed to identify those meeting the oligometastatic disease criteria. Results 483 of 696 were diagnosed as M1 disease. OMD was found in 59 cases (12.2%), with a median age of 72 years (43 males, 16 females). T stage distribution: 3 T2, 36 T3, 20 T4. Histology: 39 adenocarcinomas, 19 squamous cell carcinomas, 1 small cell carcinoma. Metastatic sites: non-regional lymph nodes (77.9%), liver (13.6%), lung (5.1%), bone (1.7%), adrenal (1.7%) Location of Lymph Node Involvement: 1Para-aortic11 (23.9%)2Right supra-clavicular7 (15.2%)3Porto-caval6 (13.0%)4Retro-crural5 (10.9%)5Upper mediastinal5 (10.9%)6Left Supraclavicular5 (10.9%)7Coeliac4 (8.6%)8SMA3 (6.6%) Conclusion Our data would suggest that 12.2% of patients discussed in the MDT may potentially be candidates for a curative intent treatment pathway. Although the long-term outcomes remain unclear, this approach may define a subgroup of patients who may benefit from curative intent treatment with the highest site being para-aortic nodes.

Implementing Resourcefulness Training© with Parent Caregivers of Children Dependent on Medical Technology During the COVID-19 Pandemic: Lessons Learned from a Randomized Controlled Trial

Parent caregivers of children requiring life-saving medical technology (e.g., mechanical ventilation) report higher levels of stress and poorer health than other caregivers, often neglecting health-promoting behaviors for themselves. This article describes an iterative implementation science strategy used to improve intervention delivery for a randomized controlled trial testing a telehealth, cognitive-behavioral resourcefulness intervention with this population during the COVID-19 pandemic. This process consisted of reflective team meetings and content analysis. Initial adjustments were made after content analysis of pilot study materials before intervention delivery including an intervention script, checklist, online daily log, Health Insurance Portability and Accountability Act (HIPAA)-compliant texting option, training material access, and fidelity checks. In vivo adjustments were implemented in four areas: recruitment/engagement, participation and use of resources, in-person delivery, and virtual delivery. Our efforts to streamline intervention delivery were enhanced by incorporating an iterative implementation science strategy including analysis and adjustment of intervention delivery procedures to decrease participant burden and promote intervention adherence. Reflective team meetings and a collaborative, problem-solving approach to resolve the various barriers and challenges with the randomized controlled trial were integral components of intervention delivery. This study informs future intervention research by providing details of barriers faced, pragmatic adjustments made to intervention implementation, and lessons learned (NCT0410524; www.clinicaltrials.gov).

Format Matters: Comparing the Inclusiveness and Effectiveness of Hybrid and Remote Meetings

The surge in remote and hybrid work has provided many benefits in terms of flexibility and autonomy, but it also presents challenges when it comes to team collaboration and meetings. Using a mixed-methods field study, we compare hybrid and remote meeting configurations to better understand how to improve the inclusiveness and effectiveness of these different meeting modalities. Our findings indicate that overall, fully-remote meetings are the most inclusive and effective. Fully-remote meetings are perceived as more inclusive of remote attendees despite their lower chat usage compared to hybrid meetings. We also find that people's preferred format varies depending on the purpose or type of meeting and the skill set of the meeting moderator. We provide recommendations for improving meeting inclusion and effectiveness in both hybrid and remote meetings, such as training moderators and integrating chats with the main meeting.

Educational teams: building professional and organizational learning communities

Quality education that prepares young people to think and make ethically responsible decisions seems to be the only sustainable solution to respond to today’s global challenges. However, this capacity to learn requires a new school grammar, through the creation of conditions, structures and cultures that promote relationships and synergies capable of transforming teachers and school leaders into creative learners and facilitators of learning. In this sense, this study sought to understand the effects of a change in the organizational dynamics of a school, the organization of teaching by educational teams, on the individual, collective and organizational learning of this school organization. To this end, we adopted a fundamentally qualitative research approach, which we operationalized through a case study, based on a quali-quanti approach. We combined a descriptive statistical analysis of two questionnaires with a content analysis of interviews, focus discussion groups, and field notes from classroom observations and educational team meetings. The analysis of all these data points to the fact that effective change in schools and education that promotes deep learning for teachers and, consequently, for students and the organization, requires joint and articulated action not only at the level of structure and leadership, but also at the level of beliefs and school cultures.

The effects of spondylodiscitis on the inflammation burden in infective endocarditis.

This study investigates the effects of spondylodiscitis on the inflammation burden in infective endocarditis patients. Aprospective, observational study was conducted between September 2018 and October 2022 in anon-surgical teaching hospital. Patients with adefinite or possible and treated as infective endocarditis were recruited from the Alkmaar Endocarditis Team meetings. Spondylodiscitis was diagnosed based on symptoms and radiological findings. The inflammation burden was defined as the area under the C‑reactive protein (CRP) curve. 174 consecutive patients with infective endocarditis were included (mean age73years, 34.5% female). Concomitant spondylodiscitis was present in 32patients (18%), frequently associated with Streptococcus species (38%). At admission, the mean level of CRP was significantly higher in patients with concomitant spondylodiscitis (p = 0.004). The median CRP area under the curve was significantly higher in spondylodiscitis patients (4.2 × 106 min.mg/l [1.2 × 105 - 1.6 × 107 min.mg/l] vs 2.0 × 106 min.mg/l [8.7 × 104 - 1.6 × 107 min.mg/l], p < 0.001). This difference remained during the whole treatment period. At 6months of follow-up, rates of mortality and relapse of infective endocarditis were not significantly different. The prevalence of spondylodiscitis in non-referred patients with infective endocarditis was 18%. Endocarditis patients with spondylodiscitis had an increased inflammation burden at and during admission. This difference in normalisation of CRP levels was particularly apparent in the final phase of antibiotic treatment but not related to infectious complications. Despite an augmented inflammation burden, spondylodiscitis was not associated with mortality, cardiac surgery or infectious relapse.

Neoadjuvant chemotherapy in breast cancer: a retrospective pathway assessment in a regional cancer centre.

The optimal care pathway (OCP) for people with breast cancer provides a framework for investigation and management of patients with breast cancer, with delays previously identified regionally. With emphasis on the neoadjuvant pathway, the primary aim of this study was to assess the practicality of implementing the breast cancer OCP timeframes regionally in comparison to nationally referenced standards. A retrospective institutional audit was performed for patients undergoing neoadjuvant therapy for breast cancer. The time from referral to specialist review, completion of investigations, discussion at multidisciplinary team (MDT) meetings, initiation of neoadjuvant chemotherapy (NACT) and surgery were calculated and compared to OCP. Fifty-three patients were included, with 19 patients living rurally (36%). Twenty-four patients (45%) were seen by a specialist surgeon within 2 weeks of referral. Following surgical review, 44 patients (83%) completed investigations within 2 weeks, and 43 patient cases (81%) were discussed at MDT meetings within 2 weeks. Forty-eight patients (91%) were commenced on neoadjuvant treatment within 4 weeks of decision to treat, and 43 patients (81%) underwent surgery within 6 weeks of neoadjuvant treatment completion. Delays from initial referral to NACT were more frequent in rural patients compared to urban (79% vs 94%, P < 0.05). Adherence to OCP timeframes for patients undergoing neoadjuvant therapy in a regional centre was feasible and strategies are needed to bridge gaps identified for rural patients.

Assessment of Professional Practices in the Care Pathway of Patients with Upper Aerodigestive Tract Cancer in a University Hospital

Objectives: The main objective of this study was to evaluate the alignment between treatment decisions made during multidisciplinary team meetings (MTMs) and the treatments received by patients with upper aerodigestive tract cancers. The secondary objective was to identify factors influencing potential discrepancies. Methods: This retrospective, single-center study was conducted at a tertiary referral center and included 147 patients diagnosed with squamous cell carcinoma of the upper aerodigestive tract. Patients were divided into two groups based on the match between MTM-decided and actual treatments. Multivariate analysis was performed to assess factors independently associated with discrepancies. Results: Out of 147 patients, 28 (19%) received treatment that did not align with MTM decisions. Among these, eight died before treatment, one patient refused care, five received supportive care, five patients underwent surgery, three received radiotherapy alone, one patient underwent surgery and adjuvant radiochemotherapy, one patient underwent surgery and adjuvant radiotherapy alone, three patients received radiochemotherapy, and one patient received palliative chemotherapy. Independent significant factors associated with non-concordance included poor performance status (PS) and treatment not received at a tertiary reference center. Treatment shifts mainly involved downgrading from curative to palliative care. Conclusions: This study highlights the importance of patient health status in determining deviations from MTM decisions. Further efforts should focus on improving the integration of patient comorbidities and health status into MTM decision-making to optimize care delivery.

Increasing the uptake of advance care directives through staff education and one-on-one support for people facing end-of-life.

An advance care plan outlines a patient's wishes regarding medical treatment or goals of care in the case that they become unable to communicate or to make decisions. An advance care directive (ACD) is an advance care plan that has been formally recorded and has legal status. Despite ACDs playing an important role in person-centred end-of-life care, an earlier retrospective medical records audit demonstrated that only 11% (58/531) of people who died due to a terminal illness had an ACD.The aim of this project was to increase the proportion of patients with a terminal illness completing an ACD. A secondary outcome was to measure the impact of ACDs on hospital and intensive care unit (ICU) admissions in the last 6 months of life.This multifaceted project comprised (1) education for health professionals and the public; (2) individual support for patients on request; (3) development of online resources for health professionals and the general public; and (4) monthly team meetings. The proportion of ACDs completed and hospital and ICU admissions during the last 6 months of life, were extracted via medical record audits.Written consent was required for patients to participate, including being contacted by the project team and accessing their medical records. 112 patients consented to participate in the project and 109 (97%) completed an ACD. There was no reduction in the average number of hospital admissions, while ICU admissions reduced from 14% (n=74) to 0%. The targeted, multifaceted approach to education and support for completion of ACDs, resulted in a significant increase in ACD completion and a major reduction in ICU admissions.

Access to phage therapy at Hospices Civils de Lyon in 2022: Implementation of the PHAGEinLYON Clinic program

ObjectivesTo describe the set-up in 2022 of the PHAGEinLYON Clinic program dedicated to improve access to phage therapy in France using pharmaceutical-grade phages. MethodsWe described the process, prospectively collected all phage therapy requests received during 2022 and reviewed them retrospectively to analyze the decision and also the patient care pathway (NCT05883995). ResultsAmong 143 phage therapy requests, the indication was confirmed by multidisciplinary team meetings for 57 (40%) of them, and 44 were infected with bacteria that could be easily targeted by phages in France. Finally, 33 patients were treated, including 26 at our institution as compassionate use or in a clinical trial. Main indications were complex bone and joint infections, endovascular infections and lung infections. To manage these patients, 172 pharmaceutic phage cocktails targeting S. aureus and/or P. aeruginosa were prepared; 57 were dedicated to local, and 99 to intravenous injections. During the follow-up, 18 (69%) patients had a favorable clinical evolution, 6 (23%) required subsequent phage therapy, with the same phages with a greater phage exposition, or with different phages from elsewhere. ConclusionsThe implementation of the PHAGEinLYON Clinic program in 2022 was associated with a groundbreaking access of phage therapy in France.

Perspectives on virtual intercultural communication in the Irish-based technology sector

Abstract This mixed-methods study investigates English-medium oral online intercultural communication within the Irish-based international technology sector. The initial phase of the research consisted of a survey investigating participants’ (N = 113) experiences of virtual communication. Following the survey, to linguistically investigate such interactions, the International Virtual Team Corpus (IVT Corpus) was created. This corpus consists of approximately 80,000 words of transcribed speech gathered from 30 web-based recordings of meetings, which include both Irish and international colleagues speaking in English. This paper reports on some of the relevant quantitative and qualitative survey results, uncovering both preconceptions and embodied experiences of international virtual meetings. Following this, it presents corpus-based results of significant frequent and keyword clusters that provide a window into the discourse patterns of international virtual team meetings in this sector. Some tentative implications and applications for work-based virtual communication are explored in the closing discussion.

The meaning of organizational culture and structure for interprofessional collaboration

Abstract In Germany, early neurological rehabilitation (ENR) acts as a link between acute inpatient care and rehabilitation, aiming to restore patients’ ability to rehabilitate amid their complex clinical conditions. Interprofessional cooperation (IPC) is crucial for harmonized treatment due to patients’ vulnerability. An interprofessional team comprising medical, nursing, and various therapy professionals is essential for this purpose. To explore the meaning of organizational culture and structure to IPC, 15 group discussions in 5 clinics were conducted with n = 76 participants. 1. Weekly team meetings are used to coordinate treatment goals and outcomes, but their implementation varies from clinic to clinic. Two types of meetings were identified: those that focus primarily on billing compliance and others that address patients’ long-term perspectives. However, both require additional social service involvement and are not sufficient to adequately address daily tasks, requiring additional IPC coordination. Some clinics have therefore introduced daily meetings to improve the coordination of IPC tasks. 2. Therapy planning and therapist assignment shape IPC and task fulfillment. Three therapy planning methods were observed: centralized, block-based, and flexible, each with different therapist allocation strategies. Centralized planning with flexible allocation leads to appointment pressure and interprofessional communication challenges. Block therapy reduces therapist turnover and promotes better interprofessional coordination in patient care. Flexible therapy planning is conducted through daily interprofessional meetings with shared task allocation and planning leads to a shared understanding. Initial analysis underscores the meaning of organizational structure on interprofessional task fulfillment in ENR, emphasizing the importance of enhancing different cooperation formats which can balance stability and flexibility and integrate social services effectively in patientcare. Key messages • Morning interprofessional meetings on the ward facilitate flexible responses to daily changes in patients’ health conditions and promote interprofessional collaboration. • The consideration of occupational group-specific processes in ward organization is a necessary structural prerequisite for successful interprofessional collaboration.

The importance of Method 300 to improve the mathematical foundation of first-year STEM Brazilian undergraduates

This research explores strategies to support first-year STEM Brazilian undergraduates in two programs, computer science and mathematics, through partnerships among faculty and student members and the implementation of an active methodology known as “Method 300” within an elementary mathematics course. The primary goal of these initiatives was to enhance the academic performance of freshmen. In Method 300, for students to benefit from grade improvements, they must assist each other, regularly attend team meetings, and commit to the activities that constitute the method. The method was implemented only during the first half of the course, fortunately it also implicated into the second part of the course, showing that a tenth of the students who performed poorly at the beginning achieved satisfactory and excellent performance in the last assessment, even though the content was more complex. According to the assessment system of the whole course, by monitoring students who initially had poor academic performance, it was found that half of them achieved satisfactory performance by the end of the course, which contributed to a final approval rate above 73% of all students. The condition of student heterogeneity is crucial for the effective application of Method 300; without it, this could become a potential limitation to its successful implementation. In addition to this strategy, the course was supported by voluntary extracurricular tutors, although these were underutilized by the freshmen, prompting us to consider new ways of providing support. These results suggest that future research in this field should focus on improving students’ academic performance by systematically replicating Method 300 in other courses for freshmen students.

Improving the efficiency and person-centredness of occupational therapy input into care-plans in a forensic mental health and rehabilitation service

Care-planning is vital to the delivery of timely, person-centred, safe and effective care. Despite the understanding of the benefits of person-centred care-plan in both services, occupational therapists (OTs) within our...

Patient Participation in Multidisciplinary Team Meetings in Residential Mental Health Services: An Explorative Study of Patients' Perception.

The lack of evidence of mental health patients' perception on patient participation in multidisciplinary team meetings (MTMs) is a potential threat to the person-centeredness of care. To explore the perceptions of mental health patients regarding patient participation in MTMs and to identify factors associated with these perceptions. In a cross-sectional study, 127 former and 109 currently admitted mental health patients completed the Patient Participation during Team Meetings Questionnaire (PaPaT-Q). The STROBE-checklist was used for reporting the study. Overall, patients' perceptions were positive. Former patients expressed greater willingness to participate in MTMs, considered participation as more important, and felt more competent. These patients also exhibited a stronger preference for an autonomous role in medical decision making when participating in MTMs. The perception varied across factors such as gender, educational level, nature of psychological complaints and prior experience(s) with participation in MTMs. These findings may help mental healthcare professionals to become more aware to factors associated with mental health patients' perception of patient participation in MTMs. The results can be used by mental healthcare professionals to motivate mental health patients in an even more tailor-made basis to participate in MTMs when admitted in a hospital.

What is the carbon footprint of academic clinical trials? A study of hotspots in 10 trials

BackgroundClinical trials are fundamental to healthcare, however, they also contribute to anthropogenic climate change. Following previous work to develop and test a method and guidance to calculate the carbon footprint...

Role of Strategic HRM as Mediator of Intellectual Assets and Knowledge Sharing of Hotel Performance in West Java

In addition to examining the factors affecting organizational performance and hotel performance, this research aims to investigate the relationship between knowledge sharing and intellectual assets and hotel strategic human resource management (HRM). To create a robust knowledge culture, strategic HRM and hotel management should collaborate. This can be accomplished by holding team meetings, workshops, employee development programs, and discussion forums to promote cooperation and knowledge exchange among staff members. Maintain a competitive edge in the hospitality sector, while offering visitors outstanding service. This research was done using quantitative methods. In this study, 185 employees served as samples. Structural equation modeling was used in the analysis method (SEM). The findings demonstrated that knowledge sharing and intellectual assets impact the hotel’s strategic HRM. Hotel performance is impacted by knowledge sharing and intellectual assets. Strategic HRM influences organizational performance. Intellectual assets and knowledge sharing affect hotel performance through strategic HRM. By increasing employee knowledge and skills and encouraging collaboration and continuous learning, hotels can improve organizational performance, provide superior service to guests, and stay competitive in the hospitality industry. Strategic HRM should work closely with hotel management to build a strong knowledge culture. This can be accomplished by carrying out initiatives like staff development and training, workshops, team meetings, and discussion forums to encourage collaboration and knowledge sharing among employees. Keywords: intellectual assets, knowledge sharing, strategic HRM, organizational

Perfusion MRI-based differentiation between early tumor progression and pseudoprogression in glioblastoma and its use in clinical practice

Abstract Background Early treatment effects in patients with glioblastoma are frequently discussed during multidisciplinary team meetings (MDTM), after which a decision regarding (dis)continuation of tumor-targeted treatment is made. This study examined whether a separate and systematic evaluation of perfusion MRI (pMRI) could impact such treatment decisions in the early stage. Methods This retrospective observational study evaluated the diagnostic accuracy for detecting early tumor progression of 4 different approaches including conventional MRI, pMRI with Arterial Spin Labeling (ASL), and/or Dynamic Susceptibility Contrast (DSC) MRI, and compared those to the MDTM evaluation in clinical practice. Results Sixty-five glioblastoma patients with clinical and radiological data until 9 months after irradiation were included. For all approaches, the sensitivity for detecting early true disease progression was poor to moderate (32%–62%). Area under the curve values were comparable (range 0.63–0.74), but highest for the MDTM evaluation (0.74). In the cases of inconclusive MDTM (26%), systematic pMRI evaluation showed a higher sensitivity compared to conventional MRI (respectively, 36% vs 0%), while the specificity was 100% for all MRI approaches. Multivariable regression analysis showed that a lower KPS score (OR = 0.84 [95% CI: 0.77–0.91]) and pMRI indicative of tumor progression (OR = 0.09 [95% CI: 0.02–0.52]) were independently associated with concluding tumor progression at the MDTM. Conclusion MDTM assessment in daily clinical practice has a higher diagnostic accuracy in distinguishing early tumor progression from pseudoprogression compared to a separate, systematic evaluation of pMRI. Systematic evaluation of pMRI might be helpful if the clinical MDTM assessment is uncertain.

Preoperative multidisciplinary team meeting improves the incidence of positive margins in pathological T2 prostate cancer

PurposePositive surgical margins (PSM) after robot-assisted radical prostatectomy (RARP) for prostate cancer (PCa) can increase the risk of biochemical recurrence and PCa-specific mortality. We aimed to evaluate the impact of multidisciplinary team meetings (MDTM) on reducing the incidence of PSM following RARP.MethodsWe retrospectively collected the clinical data of consecutive patients undergoing RARP at Hiroshima University between February 2017 and October 2023. The MDTM, comprising a radiologist, uropathologist, and urologist, reviewed the preoperative magnetic resonance imaging (MRI) and prostate biopsy results of each patient before RARP and considered the areas requiring attention during RARP. Surgeons were categorized as experienced or non-experienced based on the number of RARP procedures performed.ResultsIn the pT2 population, the PSM rate was significantly lower in cases evaluated using the MDTM than in those not (11.1% vs. 24.0%; p = 0.0067). Cox regression analysis identified that a PSA level > 7 ng/mL (hazard ratio 2.2799) and nerve-sparing procedures (hazard ratio 2.2619) were independent predictors of increased PSM risk while conducting an MDTM (hazard ratio 0.4773) was an independent predictor of reduced PSM risk in the pT2 population. In the pathological T3 population, there was no significant difference in PSM rates between cases evaluated and not evaluated at an MDTM. In cases evaluated at an MDTM, similar PSM rates were observed regardless of surgeon experience (10.4% for non-experienced and 11.9% for experienced surgeons; p = 0.9999).ConclusionsAn MDTM can improve the PSM rate of pT2 PCa following RARP.

Current perioperative care in patients undergoing a beyond total mesorectal excision procedure for rectal cancer: What are the differences with the colorectal enhanced recovery after surgery protocol?

Patients requiring a beyond total mesorectal excision (bTME) procedure for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) will probably benefit from enhanced recovery after surgery (ERAS) protocols. However, implementation of ERAS protocols in such groups of patients is considered challenging. The aims of this study were to evaluate ERAS-related outcomes of patients with LARC or LRRC undergoing bTME and to investigate the possibility of designing a tailored ERAS protocol. This study was divided into four phases. Phase one consisted of a literature study to compare functional recovery and postoperative outcomes in patients undergoing bTME. In phase two, outcomes on ERAS care elements in bTME were retrospectively evaluated. In phase three, differences in ERAS-related outcomes and compliance of the colorectal ERAS protocol in patients who had undergone bTME were studied. In phase four, multidisciplinary team meetings were held to develop an ERAS protocol for bTME patients. Seven studies reported on ERAS-related outcomes in patients undergoing bTME. Median length of hospital stay was 9-19 days, median stay in the intensive care unit was 2-4 days and 30-day postoperative major complication rates were 22.6%-61.3%. Seventy-five bTME patients were included for retrospective analysis. In these patients, length of stay was 9.0 days and major postoperative complications were observed in 40.0%. The overall ERAS compliance was 44.4%. Compared with the colorectal ERAS protocol, the largest differences in management were observed in the use of epidural anaesthesia, the postoperative use of urethral catheters, oral intake and mobilization. Patients undergoing bTME for LARC or LRRC are substantially different from patients treated with the colorectal ERAS protocol, regarding ERAS-related outcomes. A tailored, multimodal ERAS protocol with specific modifications was developed by an expert multidisciplinary team for patients undergoing bTME for LARC or LRRC.

Tackling hospital service burden of alcohol dependence in England: a service evaluation of alcohol care teams (ACTs) and care pathways for integrated care

Background Chronic alcohol disorder hospital admissions are increasing in England and present a huge cost to England’s health and social care costs. Hospital-based alcohol care teams (ACTs) aim to better meet these patients’ complex needs through assessment and targeted referral. This has the potential to work effectively within England’s newly established integrated care system. Methods The aim of this project was to identify in what ways ACTs can be effective in improving care pathways for complex care in a whole-system health and social care setting. We conducted semi-structured, tailored interviews with practitioners, managers and commissioners, across three hospital and community settings in one large urban region in England, comparing ACT working with non-ACT working. Results Effective pathways were enabled by the presence of an ACT, multi-agency community initiatives, assertive alcohol outreach and frequent-attender team meetings. Identified barriers were lack of systemic funding and commissioning, poor communication between agencies, lack of information-sharing and insufficient staff training. Conclusion Community outreach and in-reach between hospitals and community services enable effective care pathways when ACTs provide the point of contact. A well-resourced ACT with clear operational remit can create links between diverse agencies and enables improved wraparound care for alcohol dependent patients.