Multidisciplinary Care Conferences Research Articles

PALC-03. MEDICAL AID IN DYING: EXPERIENCE IN THE CENTER FOR CANCER AND BLOOD DISORDERS AT CHILDREN’S HOSPITAL COLORADO

Abstract BACKGROUND Medical Aid in Dying (MAiD) is now legal in 10 US states and Washington, DC, allowing terminally ill patients to self-administer medications to peacefully end their life. There is little published on pediatric hospitals’ approach to young adult patients requesting MAiD. METHODS We review the two patients who have participated in MAiD at the Center for Cancer and Blood Disorders at Children’s Hospital Colorado (CHCO). We also explore publicly available Colorado MAiD statistics. RESULTS Between 2017 and 2022, there have been 1,090 prescriptions written for MAiD medication in Colorado, 5 of which were for patients aged 18-34 (0.5%). Two of these patients were treated at CHCO. Patient A was a 26 year old male with a CNS non-germinomatous germ cell tumor whose treatment was complicated by mucormycosis and severe engraftment syndrome. He relapsed 23 months after completing therapy. He had neurologic decline including ataxia and blindness, at which time he requested MAiD. Patient B was a 24 year old male with multiply recurrent IDH-mutant medullary high grade glioma. With metastatic progression, he had many tumor-related symptoms including dysphagia, dysarthria, and weakness impacting his activities of daily living, so he requested MAiD. Both patients had multidisciplinary care conferences with neuro-oncology, social work, ethics, psychology, and palliative care. After completing psychological evaluation and all steps required by law, they were prescribed DDAMP2 (digoxin 50 mg, diazepam 1 gram, morphine 15 grams, and propranolol 2 grams). Both patients took the medications and died peacefully. Barriers encountered included infrequency of MAiD requests leading to unclear policies and processes. CONCLUSIONS Young adults represent a small but important subset of those seeking MAiD prescriptions. Despite challenges, patients were able to receive MAiD without delay in a compassionate manner. Our experience may be applicable to other pediatric hospitals facing these requests.

Off to boarding school: Exploring how physicians learn in Tumor Board.

Tumor Board (TB) is a multidisciplinary care conference tradition in adult and pediatric oncology. The Commission on Cancer requires cancer programs to hold multidisciplinary cancer case conferences. Data support improvements in clinical decision-making due to TB and perception of learning value. Data are lacking on how physician participants learn in this environment. Our exploratory, qualitative research study rooted in naturalistic inquiry explored how physician participants learn in TB. Fifteen participants were purposefully sampled and completed semi-structured interviews. Interviews were recorded, transcribed, and analyzed to produce themes. Five themes arose: (i) mutual educational goals by participating stakeholders are beneficial to educational experiences in TB; (ii) for trainees, presenting TB cases is important for learning; (iii) for attendees of TB, discussion and collaboration surrounding the content of presentations has implications for learning; (iv) participants of TB are responsible for cultivating their learning environment and teaching one another; and (v) virtual TB alters the opportunity to participate and engage with the subject matter, impacting learning for participants. Exploring TB through the lens of an educational framework is a novel approach. By identifying the facilitators and inhibitors of learning in TB, opportunities to enhance the educational process in TB are now exposed. Our study illustrates that learning in TB occurs through the cognitive apprenticeship model, and provides insight on how to best cultivate this model to improve learning. These data demonstrate the social nature of learning, and how they align with the pediatric hematology/oncology community of practice.

Screening infection prevention policies for equity impacts

Background: Infection prevention teams utilize policies to guide practice; however, some policies may inadvertently uphold institutional racism and discrimination. Our institution utilizes an equity impact assessment tool during new policy creation or existing policy updates to identify, reduce, eliminate, and prevent inequities in care. Methods: We reviewed all 119 current institution-wide policy documents related to or managed by the infection prevention division at Seattle Children’s Hospital using an institutional equity impact assessment tool. The tool asks 6 open-ended questions to help policy owners identify potential inequities and to evaluate how marginalized groups may be affected. Each policy was assessed for its potential to create or sustain inequities for patients, families, or staff. Policies determined to have potential inequities were examined for any language to suggest that equity considerations had been incorporated into the existing policy. Initial policy review was performed by 2 infection prevention physicians, and disagreements were resolved by consensus. We defined the presence of equity considerations as any explicit mention of disparate impact of the policy on marginalized groups or mitigation of such effect. Results: Of the 119 policies reviewed, 43 (36%) were identified as having substantial potential to impact marginalized groups and create or sustain inequities. Among them, 42 (98%) of these policies lacked existing equity considerations. The policies with potential equity implications covered the following categories: COVID-19 (including masking, workforce restriction, testing), visitor restrictions, tuberculosis, central-line–associated bloodstream infections (CLABSIs), multidrug-resistant organisms (MDROs), public health reporting, medical behavioral unit policies, off-site affiliate housing policies, special pathogens program (including Ebola, MERS, SARS), surgical-site infections, home care including dialysis, and occupational health-related policies. Examples of policies that did not highlight inequities included those pertaining to construction, water intrusion, and transmission-based precautions. One example of change driven by use of the equity impact assessment tool concerned communication with patients and families about tuberculosis isolation and resulted in creation of a standardized multidisciplinary care conference to better communicate tuberculosis isolation processes (including testing required, visitor restrictions, and anticipated duration of isolation) to families in their language of care. Conclusions: Hospital-wide infection prevention policies have the potential to create or sustain existing inequities. Systematic consideration of equity implications using an equity impact assessment framework could be the first step in mitigating these effects and can result in concrete actions to reduce systemic racism.Disclosure: None

1034 A Rare Case of ROHHAD Syndrome

Abstract Introduction Early diagnosis of pediatric syndromes that are rare and involve multiple systems can be challenging. Rapid onset obesity, hypoventilation, hypothalamic dysfunction, and autonomic dysregulation characterizes ROHHAD syndrome which, if undiagnosed, can lead to potentially harmful outcomes including deferring radiological workup for a neural crest tumor (which has an over 50% association) and cardiopulmonary arrest. Report of case(s) A 10-year-old female with a history of obesity, precocious puberty, recurrent hypothermia, recurrent sodium derangements, bilateral ptosis, seizure disorder, and GERD initially presented to sleep clinic as a 4-year-old in 2017 when she recently began snoring with excessive daytime sleepiness as a result of rapid onset of weight gain. BMI at that time was 99th percentile and Epworth was 11. An in-lab polysomnography revealed severe OSA with AHI 26.4 events/hour; nocturnal hypoxemia with TS90 27% and O2 nadir 70%; and sleep related hypoventilation based on elevated pCO2 on end-tidal capnometry. Patient underwent adenotonsillectomy, revision adenoidectomy, and was started on CPAP before transitioning to BiPAP over the span of the next several years with serial polysomnographies ultimately showing significant improvement of sleep apnea with AHI 5.4 events/hour. Sleep-related hypoventilation, however, remained persistent with blood gases showing pCO2 as high as 89. PHOX2B gene testing was negative and secondary causes of hypoventilation were ruled out. During this time, she was also followed by Endocrinology for suspected hypothalamic dysfunction resulting in precocious puberty, deceleration of growth rate, sodium derangements. Autonomic dysfunction was also suspected due to recurrent hypothermia including a recent admission for Temperature < 95F and ophthalmologic abnormalities including bilateral ptosis. At a multidisciplinary care conference, a working diagnosis of ROHHAD syndrome was made based on the rapid onset of obesity, hypoventilation on sleep studies and CBGs, hypothalamic dysfunction, and autonomic degeneration. Workup for neural crest tumor with MRI chest and abdomen unremarkable. Outside academic consultation was sought for management which recommended shared decision-making regarding steroids, immunosuppressive therapy (eg rituximab, cyclophosphamide), and IVIG. Conclusion For ROHHAD syndrome, there are very few documented cases in the United States and there is no known laboratory marker; diagnosis remains clinical and takes multidisciplinary collaboration, education, and a high degree of suspicion. Support (if any)

1762. A Review of Antibiotic Outcomes Data Utilizing the Multidisciplinary OPTIONS-DC Conference for PWUD

Abstract Background Persons who use drugs (PWUD) admitted for serious infections face many challenges when long courses of intravenous (IV) antibiotics are recommended. OPTIONS-DC is a structured multidisciplinary care conference used to navigate some of these challenges with harm reduction principles to consider patient preferences, decrease length of stay when safe, and support successful completion of antibiotics1. We aimed to describe antibiotic course outcomes 4 years after implementation of OPTIONS-DC. Methods We conducted a retrospective review of patients who had an OPTIONS-DC from February 2018 to February 2022. Any PWUD diagnosed with a serious infection requiring > 2 weeks of IV antibiotic treatment were eligible for an OPTIONS-DC. Data was collected via a REDCap database. R version 3.3.2 (R Core Team, 2016) was used for statistical analysis. Results 144 conferences were included, for 129 unique patients. The mean age was 39.4 with 56.3% being male. The most common infections were bacteremia (52.8%) endocarditis (36.1%), and osteomyelitis (47.9%) with a mean recommended treatment duration of 5.62 weeks (Table 1). 87 (60.4%) patients with any substance use initiated medication assisted therapy (MAT) during admission including 74.5% (79/106) of those with opioid use disorder. 112 (77.8%) antibiotic courses were completed with 71 (63.4%) completed outpatient. Of those who initiated or continued MAT during admission, 83 (74.1%) completed antibiotic therapy. Course completion was similar for those discharged home at 84% (21/25) or to a Skilled Nursing Facility (SNF) 81.8% (9/11). All 18 patients who received antibiotics via home infusion vendor and 17 (81%) via infusion center completed their course. 39 (39.8%) patients received long acting IV antibiotics and 23 (23.5%) received oral antibiotics to complete their course. Average out of hospital antibiotic days for those who completed their course were 30.5. Table 1.OPTIONS-DC Table 1Table 1.OPTIONS-DC Table 1 continued Conclusion The OPTIONS-DC model continues to be a useful tool by incorporating harm reduction principles and patient preferences for PWUD at our hospital. Our completion rate of 77.8% and outpatient completion rate of 63.4% are higher while the patient directed discharge rate of 8.3% is lower than what is generally reported in literature for this population2-5. Disclosures Monica K. Sikka, MD, F2G: Site research investigator.

Prenatal Diagnosis and Management of Thrombocytopenia-Absent Radius Syndrome.

Prenatal Diagnosis and Management of Thrombocytopenia-Absent Radius Syndrome.

Whole Genome Sequencing: Early Diagnostic Tool in Newborns with Refractory Seizures.

Whole Genome Sequencing: Early Diagnostic Tool in Newborns with Refractory Seizures.

Description and outcomes of patients with substance use disorder with serious bacterial infections who had a multidisciplinary care conference.

Background:Patients with substance use disorders (SUDs) and severe bacterial infections requiring prolonged antibiotic therapy represent a significant challenge to providers due to complexity of care coordination required to ensure safe and effective treatment. Our institution developed a patient-centered multidisciplinary discharge planning conference, OPTIONS-DC, to address this challenge.Methods:We conducted a retrospective review to evaluates parameters between patients who received an OPTIONS-DC and those who did not.Results:We identified 73 patients receiving an OPTIONS-DC and 100 who did not. More patients with an OPTIONS-DC were < 40 years of age (76.7% versus 61.0%, OR = 2.3, 95% CI = 1.1–4.7, p = 0.02), had positive HCV antibody testing (58.9% versus 41.0%, OR = 2.1, 95% CI = 1.1–3.8, p = 0.02), injection drug use (93.2% versus 79.0%, OR = 3.6 95% CI = 1.3–10.1, p = 0.01), used methamphetamines (84.9% versus 72.0%, OR = 2.2, 95% CI = 1.0–4.8, p = 0.04), and started inpatient SUD treatment (80.8% versus 63%, OR = 2.5, 95% CI = 1.2–5.0, p = 0.04) compared with those without a conference. The OPTIONS-DC group was more likely to be diagnosed with bacteremia (74.0% versus 57.0%, OR = 2.1, 95% CI = 1.1–4.1, p = 0.02), endocarditis (39.7% versus21.0%, OR = 2.5, 95% CI = 1.3–4.9, p = 0.03), vertebral osteomyelitis (45.2% versus 15.0%, OR = 4.7, 95% CI = 2.3–9.6, p < 0.01), and epidural abscess (35.6% versus 10.0%, OR = 5.0, 95% CI = 2.2–11.2, p < 0.01) and require 4 weeks or more of antibiotic treatment (97.3% versus 51.1%, OR = 34.1, 95% CI = 7.9–146.7, p = 0.01). Patients with an OPTIONS-DC were also more likely to be admitted between 2019 and 2020 than between 2018 and 2019 (OR = 4.1, 95% CI = 2.1–7.9, p < 0.01).Conclusion:Patients with an OPTIONS-DC tended to have more complicated infections and longer courses of antibiotic treatment. While further research on outcomes is needed, patients receiving an OPTIONS-DC were able to successfully complete antibiotic courses across a variety of settings.

Improving care for individuals with serious infections who inject drugs.

Hospitalizations for serious infections requiring long-term intravenous (IV) antimicrobials related to injection drug use have risen sharply over the last decade. At our rural tertiary care center, opportunities for treatment of underlying substance use disorders were often missed during these hospital admissions. Once medically stable, home IV antimicrobial therapy has not traditionally been offered to this patient population due to theoretical concerns about misuse of long-term IV catheters, leading to discharges with suboptimal treatment regimens, lengthy hospital stays, or care that is incongruent with patient goals and preferences. A multidisciplinary group of clinicians and patients set out to redesign and improve care for this patient population through a health care innovation process, with a focus on increasing the proportion of patients who may be discharged on home IV therapy. Baseline assessment of current experience was established through retrospective chart review and extensive stakeholder analysis. The innovation process was based in design thinking and facilitated by a health care delivery improvement incubator. The components of the resulting intervention included early identification of hospitalized people who inject drugs with serious infections, a proactive psychiatry consultation service for addiction management for all patients, a multidisciplinary care conference to support decision making around treatment options for infection and substance use, and care coordination/navigation in the outpatient setting with a substance use peer recovery coach and infectious disease nurse for patients discharged on home IV antimicrobials. Patients discharged on home IV therapy followed routine outpatient parenteral antimicrobial therapy (OPAT) protocols and treatment protocols for addiction with their chosen provider. An intervention developed through a design-thinking-based health care redesign process improved patient-centered care for people with serious infections who inject drugs.

188. Outcomes After Implementing the OPTIONS-DC Multidisciplinary Care Conference for Patients with Substance Use Disorders and Severe Bacterial Infections

BackgroundHospitalizations for patients with severe bacterial infections (SBI) and substance use disorders (SUDs) are increasing. To address the unique treatment challenges for these patients and balance appropriate medical therapy with patient goals, we implemented the OPTIONS-DC, a structured multidisciplinary discharge planning conference. All patients with SBI and SUD at our institution qualify for an OPTIONS-DC.MethodsWe performed a retrospective case-control study to evaluate differences and describe outcomes in patients who received an OPTIONS-DC compared to those who did not. Admissions were included if the patient was diagnosed with a SUD, a SBI requiring at least 2 weeks of antibiotics, consultation by infectious diseases and addiction medicine, and who were admitted between February 2018 and March 2020 (following implementation of OPTIONS-DC conferences). Patients were excluded for infected prosthetic material, pregnancy, or non-bacterial infection. Results173 admissions qualified for inclusion and 73 had at least one OPTIONS-DC. Unstable housing and psychiatric disease were common (table 1). Opioid and methamphetamine use disorders were most common and almost all SUDs were severe. Patients who received an OPTIONS-DC had less medical comorbidities, less unstable housing, and were more likely to have an opioid use disorder, use more than one substance, start MAT while inpatient, and have vertebral osteomyelitis or epidural abscess (table 2). Patients who had a conference had similar proportions of unexpected discharges (13.7% vs 17%), but a higher proportion of treatment completion (83.6% vs 69%), more days of antibiotic therapy remaining after discharge (13.9 vs 9.8 days), were more likely to discharge to an outpatient setting with family or medical support (30% vs 9%), and more likely to complete their antibiotic course with a long-acting injectable (27.4% vs 9%)(table 3). ConclusionNot all eligible patients received an OPTIONS-DC and there were significant differences in substances used, housing status and type of infections between those groups. Descriptive data suggest that OPTIONS-DC may reduce the duration of inpatient antibiotic treatment and increase likelihood of completion of antibiotic therapy, however this requires further study. Disclosures Amber C. Streifel, PharmD, BCPS, Melinta (Advisor or Review Panel member) Monica K. Sikka, MD, FG2 (Scientific Research Study Investigator)

788. Outcomes of Multidisciplinary Care Conferences for Patients with Substance Use Disorders Requiring Prolonged Antimicrobial Therapy for Severe Infections

BackgroundInfectious complications in people with substance use disorders (SUD) are rising, and while outpatient parenteral antimicrobial therapy (OPAT) is widely used in the general population, OPAT failure rates in SUD are high. Due to perceived PICC risks and OPAT safety, serious infections in people with SUD at our institution often resulted in hospitalization for the duration of treatment. Prolonged inpatient treatment is difficult to tolerate and increases healthcare costs. Our OPAT and addiction medicine teams initiated multidisciplinary discharge planning conferences (OPTIONS-DC) for inpatients with SUD requiring prolonged antimicrobials. The goal was to prioritize patient preferences regarding OPAT setting while incorporating harm-reduction principles. The goal of this study is to assess the impact and outcomes of the OPTIONS-DC.MethodsWe prospectively recorded comprehensive notes at OPTIONS-DC and retrospectively performed chart review for conferences held from February 2018 to March 2019.We performed a content analysis of OPTIONS-DC notes and patient records to identify ways that OPTIONS-DC modified care plans and prioritized patient preferences.ResultsThirty-one conferences were held during the study period. Twenty-eight patients reported substance use within 90 days, 24 used intravenous substances, 12 were homeless, 24 had a mental health diagnosis, and 20 started medication-assisted treatment during hospitalization (Table 1). For 16 patients the conference altered the definitive treatment plan to align with patient preferences while emphasizing safety, and 13 of those were changed to an outpatient setting. A total of 10 patients had a decreased length of stay, with a total of 238 hospital days saved overall. OPAT was planned at discharge for 15 patients, 11 of whom completed their OPAT course. Overall, 21/31 (68%) completed their recommended antimicrobial course and 3 were lost to follow-up.ConclusionA multidisciplinary conference that prioritizes patient preferences and uses harm reduction strategies to optimize infection treatment plans is feasible and effective. The OPTIONS-DC model has potential to expand treatment options for infections in SUD, reduce hospital days, and may serve as an example for other institutions. Disclosures All authors: No reported disclosures.

The Impact of Pediatric Palliative Care Involvement in the Care of Critically Ill Patients without Complex Chronic Conditions

Background: The impact of pediatric palliative care (PPC) is well established for children with chronic complex diseases. However, PPC likely also benefits previously healthy children with acute life-threatening conditions. Objective: To determine the incidence and impact of PPC for previously healthy patients who died in a pediatric hospital. Design: Retrospective chart review of all pediatric deaths over four years. Setting/Subjects: Patients were 0 to 25 years old, died during an inpatient stay at an academic pediatric hospital ≥48 hours after admission, and had no complex chronic conditions (CCCs) before admission. Measurements: One hundred sixty-seven patients met the eligibility criteria. Most died in intensive care settings (n = 149, 89%), and few (n = 34, 20%) received PPC consultations or services. Results: Patients who received PPC services were more likely to receive a multidisciplinary care conference than did patients without PPC support (70.5% vs. 39.9%; p = 0.001), which also occurred earlier for patients who received PPC services (seven days vs. two days before death; p = 0.04). Most patients had documented end-of-life planning in their medical records; however, this occurred earlier for patients who received PPC consultation (9.5 days before death) than for those who did not (two days before death; p < 0.0001). Patients receiving PPC support (67.7%) were also more likely to have a do-not-resuscitate/intubate order before death than those who did not (39.9%; p = 0.004). Conclusions: Pediatric patients without known CCCs who subsequently die as inpatients benefit from PPC in terms of goals of care discussions and documentation of end-of-life care preferences.

Novel malignant bowel obstruction (MBO) management program for women with advanced gynecological cancer.

158 Background: Malignant bowel obstruction (MBO) is a common and challenging clinical predicament in women with advanced gynecological cancers. However, there is a lack of evidence-based guidelines or innovative approaches to improve patient care and quality of life. We implemented an inter-professional MBO management program incorporating a nurse-led ambulatory symptom management algorithm and multidisciplinary care conferences (MCC) as hallmarks of this program. Methods: Princess Margaret Cancer Centre has piloted an inter-professional MBO management program that supports women with advanced gynecological cancers who are at risk of/have developed MBO. The MBO team includes oncologists (medical, surgical, gynecologic and radiation), palliative care physicians, diagnostic and interventional radiologists, home parenteral nutrition physicians, specialized oncology nurses, dietitians, pharmacists and social workers. Complex MBO cases are discussed at regular MCC to derive treatment consensus. A symptom-driven MBO management algorithm has been devised and all patients are educated with a personalized bowel symptom management and dietary plan. For outpatient care, patients with MBO are proactively monitored by our specialized oncology nurses via phone or an eHealth bowel application to facilitate communication of symptoms and early intervention. Access to community services and home palliative care services are utilized to support care at home. All patients are enrolled into a prospective database to assess care impact and quality. Results: A total of 145 patients have been followed through the MBO management program over 12 months. At time of data cutoff, 14 had MBO (3 inpatients and 11 outpatients) and 22 were deemed at risk of MBO. Majority patients are managed as an outpatient and avoided unnecessary emergency department episodes. Detailed methodology and data analyses will be presented. Conclusions: A successful novel MBO program incorporating inter-professional care model and nurse-led ambulatory symptom management algorithm optimizes patient care in this vulnerable population and foster collaboration in implementing best practice clinical processes.

The Effects of a Multidisciplinary Care Conference on the Quality and Cost of Care for Lung Cancer Patients

A prospective, multidisciplinary care conference (MDC) has been shown to result in measurable benefits for patients with non-small cell lung cancer (NSCLC). However whether a MDC also results in a difference in resource utilization and cost as well as whether these benefits persist across a multiinstitutional system has not been reported. This investigation compared propensity-matched patients with NSCLC whose care was coordinated through a MDC to patients without access to an MDC across a geographically diverse system of hospitals. The Premiere database (Premier Inc, Charlotte, NC) for a health system's 70 hospitals was used to identify patients undergoing treatment for NSCLC during a 5-year period. Propensity matching was used to populate an MDC and non-MDC cohort. The two cohorts were compared for the costs of staging and diagnosis as well as the timeliness and quality of care metrics. Between 2008 and 2013, 13,254 patients were propensity matched. Patient demographics and Charlson comorbidity scores were comparable after matching. Significant differences were identified in adherence to national guidelines (p < 0.0001) for staging and treatment (p < 0.0001), timeliness of care (p < 0.0001), and costs (p < 0.0001) between the two groups. This investigation found that patients with NSCLC realize improved quality and timeliness of care when that care is coordinated through an MDC. The use of an MDC was also associated with a significant reduction in cost. These differences persisted across a geographically diverse set of hospitals, providers, and patients. Prospective MDCs should be considered integral and compulsory for patients with NSCLC.

Multidisciplinary Team Strives to Improve Care of High‐Risk Patients Using a Proactive Collaborative Approach

<h2>Childbearing Poster Presentation</h2><h3>Purpose for the Program</h3> Caring for complex obstetric patients presents many challenges to obstetric nurses. Current evidence indicates that maternal mortality rates and near misses are increasing. According to the Centers for Disease Control and Prevention, chronic health conditions, such as hypertension, diabetes, and obesity are increasing and place women at higher risk of complications or adverse outcomes during pregnancy and delivery. Research has shown that approaches to reduce risk involve identifying those at high risk and using multidisciplinary care planning to optimize outcomes. Limited communication between nurses and obstetricians regarding high‐risk patients leads to nurses feeling frustrated and ill prepared. A proactive versus reactive approach to managing these patients is needed. <h3>Proposed Change</h3> To create a mechanism to facilitate interdisciplinary communication and develop an individualized plan of care to promote patient safety, and improve patient and nurse satisfaction. A multidisciplinary High‐Risk Obstetrics Committee (HROC) was formed to facilitate interdisciplinary communication and collaboration. High‐risk patients were identified before admission and an individual plan of care was developed that was aimed at promoting patient safety. <h3>Implementation, Outcomes, and Evaluation</h3> The Labor & Delivery Shared Decision Making Council recognized the need for identifying and planning care for high‐risk patients. The Iowa Model for Evidence‐Based Practice guided implementation. HROC membership included nurses, obstetricians, perinatologists, neonatologists, anesthesiologists, management, and other specialties. Meetings were held monthly to plan care of future patients and evaluate outcomes of delivered patients. Set criteria helped identify cases for referral, such as maternal cardiac conditions or neonatal fetal anomalies that require special needs postdelivery. Referrals came from physicians and nurses during antepartum checks. New cases were presented, discussed, and recommendations from various disciplines were used to develop an optimal plan of care, which was shared with appropriate staff. Postdelivery cases also were reviewed to evaluate outcomes and determine opportunities for improvement. Since July 2009, 140 patients have been referred. Feedback from staff has been positive regarding the following: improved communication and coordination of care, increased nurse confidence, ability to research rare conditions before patient arrival, include patients in multidisciplinary care conferences, and offer NICU tours. Policy changes, which also have been recommended, have led to system improvements. <h3>Implications for Nursing Practice</h3> Planning care for patients with known high‐risk conditions can prevent near misses and decrease morbidity and mortality for the mother and infant. Communication is key in providing quality patient care and creating a culture of safety.

Urologists and radiation oncologists: working together for patient care

The report by Pearce and colleagues1 on differences in management recommendations by urologists and radiation oncologists for clinically localized prostate cancer serves as an update on 2 previous reports on the subject, published respectively 1 and 2 decades earlier.1,2 It is apparent that more clinicians now use risk stratification, life expectancy and survival benefits in their management algorithms. The higher degree of concordance in management recommendations for low-risk disease reflects the improved understanding of the natural history and the concept of competing risks,2 as well as the concept of therapeutic equipoise with various options. The findings on the comfort level for both groups with “watchful waiting” will hopefully translate into successful accrual and completion of the START (Surveillance Therapy Against Radical Treatment) trial comparing active surveillance and selective delayed treatment versus immediate treatment. As the authors alluded to, the differences in recommendations for moderate-risk disease are likely multifactorial. Remunerative and “turf protection” considerations should not be, but realistically are, contributing factors. The relative lack of familiarity with the other specialty may translate into reluctance to recommend treatment modalities other than what they deliver themselves. Urologists may not be as familiar with the latest technical developments and improvements in conformal or intensity-modulated radiotherapy. Conversely, radiation oncologists may be less informed about improvements in surgical outcomes of urinary continence and erectile function preservation. This dichotomy underscores the value of multidisciplinary care conferences (MCCs), which are now functional in most, if not all, academic and many community practice settings. For urologists practising in more remote communities, advances in electronic and telecommunications are facilitating participation in tumour boards and MCCs.3 More dialogue with colleagues in other disciplines should increase the comfort level in discussing and possibly recommending alternative forms of management for our patients. The results of the survey pertaining to cryotherapy also illustrate the lack of familiarity with this modality among Canadian clinicians, as there is very limited availability and exposure to this technology in Canada, either as primary or salvage therapy. This lack of familiarity is apparent in the responses regarding side effects of cryotherapy. Only 50% of either group thought cryotherapy would likely cause significant erectile dysfunction. In fact, 80%–90% of patients have erectile dysfunction with complete prostate cryoablation. Similarly, the majority of both groups thought that urinary incontinence would occur in up to 20% of cryotherapy patients. In fact, the rate of urinary incontinence after primary cryoablation should be under 10%.4 Patients need to receive unbiased, balanced and complete information before making treatment decisions. Radiation oncologists and urologists need to be up-to-date on their own as well as related specialties to optimally provide patients with therapeutic options and recommendations.

Physician Consultation, Multidisciplinary Care, and 1‐Year Mortality in Medicare Recipients Hospitalized with Hip and Lower Extremity Injuries

To determine whether routine surgeon consultation with medicine specialists and multidisciplinary care conferences-potentially modifiable hospital characteristics-are associated with lower 1-year mortality in older adults with hip and lower extremity injuries. Retrospective cohort study. Oregon hospitals. Two thousand five hundred thirty-eight Medicare recipients aged 67 and older hospitalized in Oregon hospitals in 2002 with hip or lower extremity injuries. Demographic, injury, comorbidity, and survival information were gathered from Medicare records for 2000 to 2003. All Oregon hospitals with a qualifying case were surveyed using a structured telephone interview to collect information about routine surgeon consultations and multidisciplinary care conferences for older adult orthopedic patients. Multivariable generalized estimating equation models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between hospital characteristics and mortality. After adjusting for age, injury severity, comorbid conditions, trauma center status, and hospital annual volume of patients with hip fracture, the relative odds of dying in the year after injury for inpatients treated in settings with routine surgeon consultation with medical staff was 0.69 (95% CI 0.57-0.83) compared with patients not treated in such settings. Inpatient treatment in settings with routine multidisciplinary care conferences did not significantly affect the relative odds of dying in the year after injury (OR=1.06, 95% CI=0.89-1.26). Routine consultation by attending orthopedic surgeons with medicine or primary care specialists for Medicare inpatients is associated with better survival 1 year after injury.

Ethical Analysis of Withdrawing Ventricular Assist Device Support

To describe a series of patients with heart failure supported with a ventricular assist device (VAD) who requested (or whose surrogates requested) withdrawal of VAD support and the legal and ethical aspects pertaining to these requests. We retrospectively reviewed the medical records of patients at Mayo Clinic, Rochester, MN, from March 1, 2003, through January 31, 2009, who requested (or whose surrogates requested) withdrawal of VAD support and for whom the requests were fulfilled. We then explored the legal and ethical permissibility of carrying out such requests. The median age of the 14 patients identified (13 men, 1 woman) was 57 years. Requests were made by 2 patients and 12 surrogates. None of the patients' available advance directives mentioned the VAD. For 11 patients, multidisciplinary care conferences were held before withdrawal of VAD support. Only 1 patient had an ethics consultation. All 14 patients died within 1 day of withdrawal of VAD support. Patients have the right to refuse or request the withdrawal of any unwanted treatment, and we argue that this right extends to VAD support. We also argue that the cause of death in these cases is the underlying heart disease, not assisted suicide or euthanasia. Therefore, patients with heart failure supported with VADs or their surrogates may request withdrawal of this treatment. In our view, carrying out such requests is permissible in accordance with the principles that apply to withdrawing other life-sustaining treatments.

The effect of a multidisciplinary thoracic malignancy conference on the treatment of patients with lung cancer☆

There is a paucity of data evaluating whether a multidisciplinary conference coordinating surgery, chemotherapy and radiation therapy translates into better patient care. This article compares the experiences of patients with lung cancer before and after the formation of a prospective, multidisciplinary thoracic malignancy care conference (TMC). The records of patients with a non-small-cell lung cancer at a tertiary care hospital were reviewed for completeness of staging, multidisciplinary evaluation prior to the initiation of therapy, time from pathologic diagnosis to treatment, multimodality therapy and adherence to national treatment guidelines. The summary data of patients treated before and after the TMC were initiated, and then compared. Between 2001 and 2007, 535 patients were treated prior to the initiation of the TMC and 687 patients within the TMC. The number of patients receiving a complete staging evaluation (79%/93%: p<0.0001), multidisciplinary evaluation prior to therapy (62%/96%: p<0.0001) and adherence to the National Comprehensive Cancer Network (NCCN) treatment guidelines (81%/97%: p<0.0001) all increased significantly while mean days from diagnosis to treatment significantly decreased (29/17: p<0.0001) following the initiation of a TMC. A multidisciplinary thoracic malignancy conference increased the percentage of patients receiving complete staging, a multidisciplinary evaluation and adherence to nationally accepted care guidelines while decreasing the interval from diagnosis to treatment significantly. While the ultimate goal of treatment is to improve patient survival, the surrogate variables examined in this review indicate that patients with non-small-cell lung cancer benefit from being evaluated in a prospective, multidisciplinary care conference.

Burns as Child Abuse: Risk Factors and Legal Issues in West Texas and Eastern New Mexico

The purpose of this study were to describe risk factors for child abuse from burns and examine prosecution and conviction rates after case discussions at a multidisciplinary conference Retrospective cohort study of all pediatric burns admitted between 2001 and 2006 was performed. Registry data on age, sex, mechanism, location, and size of burn were recorded. Registry data were verified against nursing documentation for accuracy. All cases were reviewed at the multidisciplinary "care conference" to gather insight from various perspectives to make a final determination of abuse or neglect. Bivariate and multivariate analysis was used to identify factors associated with child abuse. Prosecution rates were determined by contacting child protective services and district attorney's offices. A total of 457 children were included in the analysis. Most of the children were boys (70%) and were of Hispanic origin (57%), with 30% white and 10% black. Hundred cases were suspicious for abuse after review at care conference. Younger age was a significant risk factor (OR: 0.73, 95% CI: 0.65-0.82), with the mean age of abused children being 1 (3/4) years compared with 5 (1/2) years for accidental injuries. Girls were at higher risk for abuse (OR: 1.76, 95% CI: 1.06-2.91).Torso injuries were significantly more common in abused children, an unusual finding possibly reflecting a different abuse pattern in infants compared with toddlers. Suspected abuse resulted in longer hospital stays (OR: 1.03, 95% CI: 1.01-1.07). Prosecution rates and conviction rates in the authors region are low, at only 26 and 11% of suspicious cases, respectively. Young age and female sex were positively correlated with child abuse. Prosecution and conviction rates are remarkably low, despite using a multidisciplinary care conference to review all cases and obtaining early involvement of child protective services and law enforcement.