Multidisciplinary Coordination Research Articles

Operating Room Nurses’ Role in Multidisciplinary Surgical Coordination for a Patient with a Large Abdominal Tumor and Multiple Pelvic Fractures

Operating Room Nurses’ Role in Multidisciplinary Surgical Coordination for a Patient with a Large Abdominal Tumor and Multiple Pelvic Fractures

Improving the nutritional care of oncology patients - Validation of a multidisciplinary protocol in the Spanish clinical setting

malnutrition is a very frequent problem in oncology patients and can have serious repercussions. Adequate nutritional management is cost-effective in terms of health and survival in this population, but it requires multidisciplinary coordination, specific training, and continuous follow-up. to validate the applicability and efficacy of a multidisciplinary nutritional support protocol in oncology patients. a multidisciplinary nutritional protocol was developed for oncology patients, with guidelines for screening and assessment of malnutrition, treatment, re-evaluation, and management of side effects, as well as guidance on supplementation and eating patterns. The protocol would be implemented in various clinical centers, collecting data through a structured questionnaire, registering variables before and after implementation. the protocol and its impact were implemented and evaluated in 39 centers. An improvement in nutritional care was observed, evidenced by an earlier initiation of nutritional assessment and an increase in the number of patients receiving adequate care following the protocol implementation. Problems related to inadequate malnutrition coding in the centers, limited resources, and the need for greater interdepartmental collaboration were identified. the conduct of this study provides insights into how the implementation of a multidisciplinary nutritional support protocol can improve the nutritional care received by patients and informs about the main obstacles to adequate implementation.

Public Health Involvement in United States' Vision Zero Initiatives: A Mixed-Methods Study.

Vision Zero (VZ) aims to reduce fatalities and serious injuries from road traffic crashes to zero through multidisciplinary coordination. While public health officials are often recognized as critical to VZ, their involvement in VZ across the United States has not been quantified. To explore how United States public health officials were involved in VZ development and implementation. We used a mixed-method design including a quantitative assessment of VZ plans and in-depth interviewing with VZ coordinators. United States. Twenty-two in-depth interviews with municipal (n=12) and regional (n=10) VZ coordinators and 43 VZ plans were reviewed. Public health involvement in VZ development and implementation. In the United States, 64 municipalities and 21 regional entities had first-time VZ plans published between 2014 and 2022. We abstracted a sample of municipal (n=22) and all (n=21) regional plans. Most plans described key groups involved in plan development (municipal 81.8%, regional 100%). About two-thirds (67.4%; 59.1% municipal, 76.2% regional) of the plans noted public health officials in the plan development. Most plans described the principles forming the foundation of their plan (83.7%), but few mentioned public health as part of the plan principles (22.7% municipal, 14.3% regional). Public health officials were involved in engaging the community (9.1% municipal, 33.3% regional) and providing data (22.7% municipal, 52.4% regional) for plan development, as documented in the plans. For proposed implementation, public health officials were identified as involved in: community engagement (31.8% municipal, 42.9% regional), sharing/analyzing data (40.9% municipal, 33.3% regional), and identifying/providing funding sources (13.6% municipal, 4.8% regional). The in-depth interviews provided further context and a more detailed understanding of public health involvement in VZ. Evidence from the VZ plans and interviews provided examples of how public health officials engaged in the development and implementation of VZ initiatives.

Successful ABO-Incompatible Living Donor Liver Transplantation in a Patient with an Anaphylactic Reaction to Fresh Frozen Plasma During Therapeutic Plasma Exchange: A Case Report

BackgroundABO-incompatible living donor liver transplantation (ABOi LDLT) is a complex procedure involving the reduction of anti-A and anti-B antibodies by therapeutic plasma exchange (TPE) to prevent acute antibody-mediated rejection. Fresh frozen plasma (FFP) is often used as replacement fluid during TPE. Case DescriptionWe report an ABOi LDLT case in which the patient experienced an anaphylactic reaction to FFP during TPE. Additional TPE was performed using 5% albumin as replacement fluid. ABOi LDLT was successfully performed by adapting the transfusion strategy to avoid FFP and cryoprecipitate and to administer washed platelets. ConclusionThis case highlights the importance of careful preoperative assessment, multidisciplinary coordination, and individualized approaches in ABOi LDLT, especially when the patient has an anaphylactic reaction to FFP.

Multidisciplinary care for patients with gastroesophageal cancers (GEC): A quality improvement initiative in community cancer clinics.

e16096 Background: Evidence-based guidelines for GEC management recommend multimodal care, which involves close coordination between medical, surgical, and radiation oncologists, together with specialists to manage symptoms and treatment-related adverse events (AEs). Optimizing the high level of multidisciplinary care required for effective GEC management poses substantial challenges for community oncology care teams. Methods: In August-October 2023, 57 healthcare providers (HCPs) from 4 US community oncology clinics completed surveys on challenges, barriers, and improvements needed in the multimodal care of patients with GEC. Based on findings from the baseline data, 70 HCPs participated in audit/feedback (AF) sessions to review site-specific gaps and challenges and develop action plans to address identified gaps. Follow-up surveys will evaluate the impact of changes in practice following action plan implementation. Results: Providers identified their 3 top challenges to providing care for patients with GEC: interdisciplinary care coordination, providing patient-centered supportive care, and managing AEs. They reported that care coordination was hampered by low frequency and poor-quality communication between medical oncology and surgical teams, by misalignment on methods of communication, and by a lack of relationship between the specialties. About one-third of HCPs reported recognizing and managing AEs as the most challenging aspect of caring for patients with GEC, including AEs that were immune-related (26%), dermatologic (19%), gastrointestinal (19%), neurologic (14%), immunosuppression-related (10%), and respiratory (5%). After the AF sessions, HCPs reported improving communication and coordination among care team members as an important means of improving and individualizing patient care plans and integrating new therapies into clinical workflows. Action plans included streamlining communication with surgical teams, increased use of patient navigation, and ensuring that every patient is reviewed through the multidisciplinary tumor board. With regard to AE management, action plans included improving patient education on AE identification, and better communication within the team on nutritional support. HCPs who participated showed improved confidence, knowledge, and competence in appropriately sequencing systemic therapy and surgical interventions. Conclusions: GEC care teams from community cancer clinics reported dissatisfaction with multidisciplinary care coordination, including poor communication between specialists involved in multimodal care of patients with GEC. Integration of sustainable changes in clinical workflows driven by this initiative improved oversight of multimodal care, improved workflows, and improved AE management.

Perioperative strategies and management of giant anterior mediastinal tumors: a narrative review.

Giant anterior mediastinal tumors sometimes may cause circulatory collapse and respiratory failure, known as mediastinal mass syndrome (MMS). The prediction and prevention of MMS is challenging. The aim of this study is to summarize the evaluation methods for MMS and formulate treatment strategies for giant anterior mediastinal tumors. We performed a thorough analysis of recent international literature on giant anterior mediastinal tumors (>10 cm in diameter) and MMS published in the PubMed database. The search spanned the duration of the preceding 10 years from August 19, 2023, and only studies published in English were included. Mature teratomas and liposarcomas are the most common giant anterior mediastinal tumors and MMS develops most frequently in case of malignant lymphomas. Here, we propose a new treatment strategy for giant anterior mediastinal tumors. Based on imaging findings, giant anterior mediastinal tumors can be classified as cystic or solid and further blood investigation data are useful for a definitive diagnosis. When malignant lymphoma or malignant germ cell tumor is highly suspected, the first choice of treatment is not surgery but chemotherapy and radiotherapy. Moreover, image-guided drainage may be effective if giant cystic anterior tumors develop into MMS. The risk classification of MMS is important for treating giant anterior mediastinal tumors. If the MMS risk classification is 'unsafe' or 'uncertain', the intraoperative management deserves special attention. The surgical approach should however be based on tumor localization and invasion of surrounding tissues. Multidisciplinary team coordination is indispensable in the treatment of giant anterior mediastinal tumors. When giant anterior mediastinal tumors are encountered, it is important to follow the appropriate treatment strategy, focusing on the development of MMS based on imaging findings and symptoms.

Prehabilitation in Adults Undergoing Cancer Surgery: A Comprehensive Review on Rationale, Methodology, and Measures of Effectiveness.

Cancer surgery places a significant burden on a patients' functional status and quality of life. In addition, cancer surgery is fraught with postoperative complications, themselves influenced by a patient's functional status. Prehabilitation is a unimodal or multimodal strategy that aims to increase a patient's functional capacity to reduce postoperative complications and improve postoperative recovery and quality of life. In most cases, it involves exercise, nutrition, and anxiety-reducing interventions. The impact of prehabilitation has been explored in several types of cancer surgery, most commonly colorectal and thoracic. Overall, the existing evidence suggests prehabilitation improves physiological outcomes (e.g., lean body mass, maximal oxygen consumption) as well as clinical outcomes (e.g., postoperative complications, quality of life). Notably, the benefit of prehabilitation is additional to that of enhanced recovery after surgery (ERAS) programs. While safe, prehabilitation programs require multidisciplinary coordination preoperatively. Despite the existence of numerous systematic reviews and meta-analyses, the certainty of evidence demonstrating the efficacy and safety of prehabilitation is low to moderate, principally due to significant methodological heterogeneity and small sample sizes. There is a need for more large-scale multicenter randomized controlled trials to draw strong clinical recommendations.

Clinical and economic outcomes associated with lymph node examination status in early-stage non-small cell lung cancer: a real-world US study using the SEER-Medicare linked database.

Clinical practice guidelines recommend adjuvant therapy for patients with early non-small cell lung cancer (eNSCLC), especially those with lymph node metastasis. This study evaluated the prevalence of lymph node examination and its association with adjuvant treatment rates, overall survival (OS), and healthcare costs among United States (US) Medicare patients with resected eNSCLC. This retrospective observational cohort study used Surveillance, Epidemiology, and End Results cancer registry data linked with Medicare claims data. Eligible patients were aged ≥65 years with newly diagnosed non-small cell lung cancer (NSCLC) stages IA to IIIB [the American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 7th edition] between January 2010 and December 2017 with surgery ≤1 month prior to or ≤12 months after diagnosis. Patients were grouped by lymph node examination status: no examination (pNX), examination and no metastasis (pN0), or metastasis staging in N1 (pN1) or N2 (pN2). OS and costs were evaluated by examination status and number of lymph node examined. OS was analyzed using extended Cox proportional hazards models for specific time periods and time interaction with examination status, and adjusted for patient characteristics. Adjusted post-surgical healthcare costs per patient per month (PPPM) were analyzed using gamma-log regression models. Among the 14,648 patients included in the study, approximately 11% were pNX, whereas most were pN0 (68%), followed by pN1 (11%) and pN2 (10%). Adjuvant treatment rates were higher for pNX (35%) than pN0 (18%), but lower than pN1 (68%) and pN2 (74%) patients (P<0.001). Unadjusted OS for pNX patients was nearly identical to pN2, and significantly worse compared to pN0 and pN1 (P<0.0001). After adjusting for patient characteristics, pNX patients had higher risk of death relative to pN0 patients (P<0.001). Marginal mean adjusted total costs were comparable across pNX ($15,827 PPPM), pN0 ($12,712 PPPM) and pN1 ($17,089 PPPM), but significantly less for pN0 compared to pN2 ($23,566 PPPM) (P=0.002). Inadequate lymph node examination is associated with underutilization of adjuvant treatment and poor OS in resected NSCLC. In the current era of targeted and immunotherapies, lymph node examination is more important than ever, implicating the need for Quality Improvement practices and multidisciplinary coordination.

Genetics Visit Uptake Among Individuals Receiving Clinically Actionable Genomic Screening Results

Screening unselected populations for clinically actionable genetic disease risk can improve ascertainment and facilitate risk management. Genetics visits may encourage at-risk individuals to perform recommended management, but little has been reported on genetics visit completion or factors associated with completion in genomic screening programs. To identify factors associated with postdisclosure genetics visits in a genomic screening cohort. This was a cohort study of biobank data in a health care system in central Pennsylvania. Participants' exome sequence data were reviewed for pathogenic or likely pathogenic (P/LP) results in all genes on the American College of Medical Genetics and Genomics Secondary Findings list. Clinically confirmed results were disclosed by phone and letter. Participants included adult MyCode biobank participants who received P/LP results between July 2015 and November 2019. Data were analyzed from May 2021 to March 2022. Clinically confirmed P/LP result disclosed by phone or letter. Completion of genetics visit in which the result was discussed and variables associated with completion were assessed by electronic health record (EHR) review. Among a total of 1160 participants (703 [60.6%] female; median [IQR] age, 57.0 [42.1-68.5] years), fewer than half of participants (551 of 1160 [47.5%]) completed a genetics visit. Younger age (odds ratio [OR] for age 18-40 years, 2.98; 95% CI, 1.40-6.53; OR for age 41-65 years, 2.36; 95% CI, 1.22-4.74; OR for age 66-80 years, 2.60; 95% CI, 1.41-4.98 vs age ≥81 years); female sex (OR, 1.49; 95% CI, 1.14-1.96); being married (OR, 1.74; 95% CI, 1.23-2.47) or divorced (OR, 1.80; 95% CI, 1.11-2.91); lower Charlson comorbidity index (OR for score of 0-2, 1.76; 95% CI, 1.16-2.68; OR for score of 3-4, 1.73; 95% CI, 1.18-2.54 vs score of ≥5); EHR patient portal use (OR, 1.42; 95% CI, 1.06-1.89); living closer to a genetics clinic (OR, 1.64; 95% CI, 1.14-2.36 for <8.9 miles vs >20.1 miles); successful results disclosure (OR for disclosure by genetic counselor, 16.32; 95% CI, 8.16-37.45; OR for disclosure by research assistant, 20.30; 95% CI, 10.25-46.31 vs unsuccessful phone disclosure); and having a hereditary cancer result (OR, 2.13; 95% CI, 1.28-3.58 vs other disease risk) were significantly associated with higher rates of genetics visit completion. Preference to follow up with primary care was the most common reported reason for declining a genetics visit (68 of 152 patients [44.7%]). This cohort study of a biobank-based population genomic screening program suggests that targeted patient engagement, improving multidisciplinary coordination, and reducing barriers to follow-up care may be necessary for enhancing genetics visit uptake.

The TSANZ and Lung Foundation Australia 2023 landscape survey of lung cancer care across Australia and Aotearoa New Zealand.

Unwarranted variations in lung cancer care have been well described in both Australia and Aotearoa New Zealand, with shortfalls in hospital-based workforce and infrastructure previously demonstrated. A survey of lung cancer clinicians was performed to gain an updated understanding of current workforce and infrastructure. An online Qualtrics survey included questions on institutional demographics, estimated lung cancer case load, multidisciplinary team (MDT) characteristics including workforce and local infrastructure. We sought to obtain one response from every institution treating lung cancer in Australia and Aotearoa New Zealand. Responses were received from 89 institutions, estimated to include 85% centres treating lung cancer in Australia and 100% of public hospitals in Aotearoa New Zealand. Lung cancer nurse specialist and Nuclear Medicine are poorly represented in multidisciplinary teams (MDTs) with just 34/88 (38%) institutions fulfilling recommended core workforce for MDT meetings. Case presentation is low with 32/88 (36%) regularly discussing all lung cancer patients at MDT. Metropolitan institutions appear to have a more comprehensive range of services on site, compared to non-metropolitan institutions. Few (4/88) institutions have embedded smoking cessation services. Compared to the previous 2021 Landscape Survey, thoracic surgery representation and core MDT workforce have improved, with modest change in specialist nurse numbers. This wide-reaching survey has identified persistent deficiencies and variations in lung cancer workforce and gaps in infrastructure. Multidisciplinary collaboration and care coordination are needed to ensure all patients can access timely and equitable lung cancer care.

Mapping the Discharge Process After Surgery

Care transition models are structured approaches used to ensure the smooth transfer of patients between health care settings or levels of care, but none currently are tailored to the surgical patient. Tailoring care transition models to the unique needs of surgical patients may lead to significant improvements in surgical outcomes and reduced care fragmentation. The first step to developing surgical care transition models is to understand the surgical discharge process. To map the surgical discharge process in a sample of US hospitals and identify key components and potential challenges specific to a patient's discharge after surgery. This qualitative study followed a cognitive task analysis framework conducted between January 1, 2022, and April 1, 2023, in Veterans Health Administration (VHA) hospitals. Observations (n = 16) of discharge from inpatient care after a surgical procedure were conducted in 2 separate VHA surgical units. Interviews (n = 13) were conducted among VHA health care professionals nationwide. Postoperative hospital discharge. Data were coded according to the principles of thematic analysis, and a swim lane process map was developed to represent the study findings. At the hospitals in this study, the discharge process observed for a surgical patient involved multidisciplinary coordination across the surgery team, nursing team, case managers, dieticians, social services, occupational and physical therapy, and pharmacy. Important components for a surgical discharge that were not incorporated in the current care transition models included wound care education and supplies; pain control; approvals for nonhome postdischarge locations; and follow-up plans for wounds, ostomies, tubes, and drains at discharge. Potential challenges to the surgical discharge process included social situations (eg, home environment and caregiver availability), team communication issues, and postdischarge care coordination. These findings suggest that current and ongoing studies of discharge care transitions for a patient after surgery should consider pain control; wounds, ostomies, tubes, and drains; and the impact of challenging social situations and interdisciplinary team coordination on discharge success.

DOP04 Screening and management of fistula cancers in patients with perianal fistulising Crohn’s Disease: an expert consensus

Abstract Background Fistula cancer is a rare and often devastating diagnosis in patients with perianal fistulising Crohn’s disease (CD). Fistula cancer management is a complex process requiring multi-disciplinary effort. However, given the low incidence and subsequent lack of data and clinical trials in the field, there is little to no guidance on screening and management of fistula cancer. To inform clinical practice, we developed consensus guidelines on fistula cancer in perianal fistulising Crohn’s disease by multidisciplinary experts from the international TOpCLASS consortium. Methods We performed a systematic review of the literature by standard methodology, using the Newcastle-Ottawa quality assessment tool. Data were retrieved from articles according to these domains: epidemiology and risk factors, clinical presentation, diagnostics, staging, and treatment. We developed consensus statements using a Delphi consensus approach. Participants included gastroenterologists, surgeons, radiologists, and pathologists. We performed two rounds of voting: (1) online survey followed by statement edits and (2) hybrid meeting with discussion until over 80% consensus was achieved for each statement. Results Of 550 articles identified, 99 were eligible, and 80 articles were included. The overall quality of evidence was low. Seven statements were accepted in the final consensus (Table 1). Patients with longstanding (&amp;gt;10 years) perianal fistulising CD should be considered at small but increased risk of developing fistula cancer, including anal squamous cell cancer (SCC) and anorectal carcinoma. Risk factors for anal SCC, including human papilloma virus (HPV), should be considered. Clinical signs and symptoms of fistula cancers are non-specific, and several case reports included asymptomatic patients. New or refractory/progressive perianal symptoms should prompt evaluation for fistula cancer. There was no consensus on timing or frequency of screening in patients with asymptomatic perianal fistula. Regarding diagnostics, multiple modalities may be required, including repeated exam under anesthesia with biopsy. Multidisciplinary team efforts were deemed central for the management of fistula cancers. Conclusion Clinicians managing patients with perianal fistulising CD should be aware of the risk of fistula cancers, including anal SCC and anorectal carcinoma. Our expert consensus recommends consideration of patient factors including duration of fistulas, HPV status, and perianal symptoms, and gives guidance on diagnostic modalities and treatment considerations. Multidisciplinary coordination of care is paramount, and more studies in the field are needed.

BIM multitask project manager: responsibility, organization and interoperability

Building Information Modelling (BIM) methodology has been supporting the construction activity in all sectors involved: multidisciplinary designs development; construction planning and monitoring; building management and maintenance. A BIM environment aggregates several specialties and related professionals and in order to control and improve the quality of a BIM project, a BIM manager is required. The BIM manager has the responsibility to coordinate all tasks involved in a building design and in the associated activities that are usually workout over the project documents. A BIM platform can be considered as a useful resource for multidisciplinary coordination, extending the BIM 3D modelling scope into the construction planning and after, in the operation and maintenance stages. A BIM manager is then required: to incentive the collaboration at work and to control responsibility given to each professional involved; to guaranty the correction of the amount and quality of the information, included in each BIM model step, and transferred between tasks; to coordinate all designs and the distinct mandatory activities (conflict detection, cost estimation or energetic simulation). The topic of the present study is illustrated with three building cases were distinct specific projects, disciplines and tasks were developed: structural analyses and reinforcement details; quantity take-off of materials and cost estimation; construction scheduling and simulation. The study presents the relevance of a correct coordination within the development of building projects. Although there are limitations in the implementation of BIM methodology in all sectors or activities within the construction industry, BIM has been bringing an important improvement in the quality of a building design, reflected in the quality of the final product. BIM methodology is a current demand in the construction industry supported on advanced technology and in an adequate management of projects.

Role of primary care for individuals with childhood-onset neurologic conditions

BackgroundIndividuals with childhood-onset neurologic conditions often face challenges in the pediatric-to-adult health care transition (HCT). Furthermore, the importance of implementing primary care is unrecognized. We investigated the situation of adults with childhood-onset neurologic conditions from the perspective of health care professionals (HCPs) in community- and hospital-based primary care practice. Design and methodsOverall, 1334 HCPs in medical facilities across Tokyo (mainly in Kita, Nerima, and Itabashi Cities) were surveyed regarding their experience caring for adults with childhood-onset neurologic conditions. Snowball sampling was also deployed to enhance the input from various health professions. The questionnaire included quick response codes linked to web-based questionnaires identical to paper-based ones, enabling additional HCPs to answer the questionnaire. The survey included questions about the care provided by HCPs, the perceived challenges and worthwhileness of the care, and their views on HCT. ResultsWe collected 276 responses (response rate, 20.7%): 224 by mail and 52 online. In total, 94 HCPs of the respondents (75 doctors, 11 nurses, 5 therapists, 2 care workers, and 1 medical social worker) involved in caring for this population were analyzed. Doctors and nurses managed medical devices, educated patients, and provided consultation and care. Doctors cited the management of comorbidities outside of their expertise and difficulties securing hospitalization during emergencies as barriers to care. HCPs found the valuable opportunities to enrich their clinical experience and long-term relationships with patients worthwhile. HCPs expressed the need for systems that guarantee patient hospitalization and multidisciplinary conferences between HCPs and specialists. ConclusionWe described the roles of HCPs in community- and hospital-based primary care, which are vital components of HCT for adults with childhood-onset neurologic conditions. Their practice includes multidisciplinary involvement, patient education, and care coordination. For better HCT in this population, efforts are required to enhance HCPs’ capability to respond to patients with disabilities, patients’ multiple comorbidities, and families’ needs. Practice implicationsFurther efforts to deepen community-based care are desired to improve HCT for people with childhood-onset neurologic conditions.

Clusters of medical specialities around patients with multimorbidity – employing fuzzy c-means clustering to explore multidisciplinary collaboration.

Background: The increasing prevalence of multimorbidity challenges hospital care organization. Hospital care is structured around medical specialties and focused on separate treatment of individual organ systems. Consequently, patients with multimorbidity visit multiple healthcare professionals and have high healthcare utilization with a risk of interactions and contradictory treatments if multidisciplinary coordination is absent. Organizational structures for multidisciplinary collaboration between medical specialists in case of multimorbidity are, however, limited. To facilitate multidisciplinary, coordinated care and to prevent or minimize adverse health outcomes, it might be useful to organize hospital care around specific patterns of multimorbidity or medical specialties. Therefore, we hypothesized that the use of cluster analysis and real clinical data could be helpful to unravel groups of medical specialties who are simultaneously involved in hospital care for patients with multimorbidity. &#x0D; Method: We performed a cross-sectional cohort study and used retrospectively collected electronic health record (EHR) from a Dutch hospital in 2017. We extracted EHR data of 22,133 patients with multimorbidity aged ≥18 years who had received outpatient clinical care for two or more chronic and/ or oncological diagnosis. We used a fuzzy c-means clustering algorithm and explored the patients’ membership degree factors to each cluster to distinguish subgroups of patients with a specific pattern of involved medical specialties.&#x0D; Results: The mean age was 67.9 years (interquartile range (IQR):20.9), and 56.0% was female. We identified six clusters and 22 subgroups. The clusters were: 1. dermatology/ plastic surgery, 2. six specialties, 3. pulmonology, 4. internal medicine/ cardiology/ geriatrics, 5. neurology/ rehabilitation/ anesthesiology, and 6. internal medicine. Most patients had a full or dominant membership to one cluster only (11 subgroups) and the remaining subgroups were combinations of two clusters. The prevalence of specific diagnosis groups, patient characteristics and healthcare utilization seemed to differ between subgroups. For instance, patients of the subgroup with high involvement of internal medicine, cardiology and geriatrics; was characterized by cardiometabolic diseases. These patients had the highest average age (median:73 years, IQR:16.2), number of diagnoses (median:5, IQR:3), and number of outpatient visits (median:7, IQR:6). Patients of the subgroup with involvement of both the cardiologist and pulmonologist had lower number of diagnoses (median:3, IQR:1) and outpatient visits (median: 5:, IQR:4). This subgroup was mostly characterized by pulmonary and heart diseases, which can both represent with symptoms as dyspnea. Thus, the subgroups and their characteristics can provide clues about potential target populations that might benefit from (more) multidisciplinary collaboration, such as a formalization of a cardiometabolic or dyspnea outpatient clinic. &#x0D; Conclusion: Our study shows that it is possible to use fuzzy c-means cluster analysis and real clinical data to identify clinically relevant clusters and subgroups of medical specialties simultaneously involved in hospital care for patients with multimorbidity. With this strategy hospitals, healthcare professionals, and data scientists can further analyze which of these subgroups are target populations with multimorbidity that might benefit from improved multidisciplinary collaboration or new models of care.

Dementia coaching: the missing link in primary care

Introduction: Each Belgian township has inhabitants who suffer from dementia and this prevalence will continue to rise. Not only Belgium but also other European countries are facing this increase.&#x0D; In Belgium, on average 70% of people with dementia are living and receiving care at home.&#x0D; Policy Context And Objective: There are many services available for people with dementia. The organization of these services is however, highly fragmented and difficult to navigate. Additionally, the multidisciplinary integration and coordination is limited.&#x0D; In 2015, the Belgian government approved a plan called “Integrated Care for a better health”, which led to the development of 12 pilot projects that aim to provide high quality care and support to patients through the implementation of different actions. One of these actions in the Waasland regional project aims to target the challenges as described above through the dementia coaching approach. This approach was developed and implemented bottom-up since 2019, with the input of informal caregivers and the Alzheimer’s patient organization.&#x0D; Subsequently, in 2021 a similar approach was developed for people with Parkinson’s disease.&#x0D; Target Population: The action targets people who are diagnosed with dementia, as well as their informal caregivers in the Waasland region. In October 2022, already 216 families have received guidance from one of the regional dementia coaches.&#x0D; Highlights: The dementia coaching approach is a unique initiative that targets coordination of care across organizations. It aims to be the “missing link” through a multidisciplinary coaching team of both self-employed coaches and coaches employed by the different regional health care organizations. Their main task is to assist in navigating the regional health systems and organizations, by house and/ or telephone calls.&#x0D; The regional hospital is an additional partner of the project alongside the primary care organizations.&#x0D; The approach aims to improve the perceived quality of care as well as patient empowerment. The project is continuously evaluated and improved based on its user experiences. The coaches need to follow a mandatory training and participate in peer reviews to ensure that they share a quality-based vision and approach.&#x0D; Since dementia coaching receives state funding for the pay of the coaches, it allows the approach to be offered without additional costs for its users. This improves accessibility of care.&#x0D; &#x0D; Transferability And Conclusion: The dementia coaching approach is already being implemented for people with Parkinson’s disease. The approach shows possibilities to be transferred to other target populations as well (e.g. other chronic diseases) and could be useful for people with comorbidities. This option is currently being explored.&#x0D; Additionally, the approach has the potential to be implemented in other regions and/or countries that are willing to add this missing link.&#x0D; Key words: pilot projects – co-creation – dementia – chronic disease - integrated care&#x0D; &#x0D;

Caring for Long Covid patients in Belgian primary care.

Background: The Covid-19 pandemic affected primary health care in various ways and general practitioners (GPs) take a key position in caring for patients with persistent Covid-19-related symptoms, also referred to as Long Covid. In this study, GPs’ knowledge, experiences and opinions on Long Covid, as well as the definition being used by GPs is investigated to provide more insight in the care for Long Covid patients in primary care.&#x0D; Methods: An online questionnaire, validated by experts, was distributed to all Belgian GPs through established national GP networks (SGP network, Domus Medica and SSMG) during spring 2022. The survey has 16 (ordinal, open-ended or multiple choice) questions on Long Covid. To characterize GPs, practice and demographic characteristics were collected. A case definition for Long Covid was not included, as there was no widely accepted definition available in general practice at the timing of the study. Descriptive and analytic statistics were performed.&#x0D; Results: A total of 105 GPs responded to the survey. GPs were well distributed across all Belgian regions and practice type. Female GPs represented 58.1% and mean age was 51 years (IQR: 38-63).&#x0D; Most of GPs reported that they did not have sufficient scientific knowledge on Long Covid, they reported lack of availability of reliable information on Long Covid diagnosis and treatment, and felt that accessibility to educational material on Long Covid was limited.&#x0D; For the diagnoses of Long Covid, 60.0% reported that a positive Covid-19 test result is a minimum requirement when speaking about Long Covid complaints. The commonest criteria utilized by GPs for diagnosing Long Covid was the duration of symptoms (from 4 weeks to 5 months) and on the basis of diagnostic criteria by the GP. 58.1% of GPs stated that Long Covid should be considered a chronic disease.&#x0D; The majority (75.2%) of participating GPs reported to have cared for Long Covid patients (independently of practice type, GP’s gender or age). These patients suffered mainly from fatigue (94.9%), concentration/memory problems (74.7%), breathing difficulties (68.0%), impairment in daily functioning (66.7%) and brain fog (46.2%).&#x0D; Most GPs (93.4%) believed that caring for Long Covid patients should follow multidisciplinary approach. Half of them (51.9%) reported to have been following up these patients by themselves or by GP colleagues and 32.9% by multidisciplinary cooperation. Other healthcare professionals involved include pneumologists, physiotherapists, specialists in physical medicine/rehabilitation and neurologists. GPs were consulted biweekly (17.9%), monthly (47.8%) or every few months (19.4%) by these Long Covid patients. &#x0D; Conclusion: In Belgian general practice, similar definitions and diagnostic criteria are used by GPs to identify Long Covid patients. A majority of GPs frequently provide care to Long Covid patients and GPs take a key role in the (multidisciplinary) coordination of care for these patients. However, multidisciplinary care for Long Covid patients is less organized than preferred by GPs at the timing of the study (spring 2022). With the establishment of the ‘care trajectory post-Covid-19’ for Long Covid patients in primary care since July 2022, collaboration between care givers may be stimulated in Belgian primary health care.

Closing the Gap: Multidisciplinary Coordination of a Care Plan for Patients with Multimorbidity

Introduction: Multidisciplinary communication and collaboration are of utmost importance in order to transition from fragmented and disease-centered care to patient-centered care for people with multimorbidity. Interdisciplinary coordination of a care plan is a vital part of this collaboration, yet can take many different forms. Our primary aim is to uncover the existing pathways of multidisciplinary communication and collaboration to reach an integrated treatment plan. Our secondary aim is to identify potential limitations and strengths of these pathways, in order to propose ways to improve interdisciplinary coordination, and ultimately improve outcomes of care for patients with multimorbidity in the hospital.&#x0D; Methods: Seven focus groups were organized, in both secondary and tertiary hospitals in the Netherlands. Each focus group was centered around a recent, local case study regarding a patient with multimorbidity. All involved health care professionals related to this specific patient were invited to participate in the focus group. Focus groups followed a discussion guide and were transcribed verbatim. Text was fragmented, coded and thematized using the principles of grounded theory. Member checking was performed by experts in the field.&#x0D; Results: 20 medical professionals were interviewed from three secondary, and four tertiary hospitals. None of the focus groups included all invited professionals due to their conflicting schedules. Analysis showed that the process of interdisciplinary coordination could be divided into the ‘reason’, ‘timing’, ‘modality’ and ‘outcome’. The ‘reason’ to seek interdisciplinary coordination could be medical complexity, a signal from a patient that indicates uncoordinated care, need for division of care roles, or to explore if care plans are aligned with the patient as a whole. Care providers could opt for different modalities to collaborate, such as: a phone call, referral to a colleague, or organizing a multidisciplinary team meeting. Possible outcomes could be integrating patient goals into the care plan, reduction in care consumption, and/or higher patient satisfaction. Factors of influence were identified for all main elements of this process: e.g. level of experience of the health care professional and available financial structures for different modalities of collaboration.&#x0D; Implications: We introduce a process model describing the current pathways in multidisciplinary coordination of care for patients with multimorbidity. This model shows that depending on the reason to collaborate, and with the desirable outcome in mind, different modalities of collaboration and communication are possible. Using case studies, we illustrate how and where current pathways can fall short and new innovative ways of providing care can be developed. For the Netherlands, we are developing a new mode of seeking coordination based on this model which ensures better multidisciplinary collaboration and inclusion of the patient perspective: a structured multidisciplinary patient review (MPR) for patients with multimorbidity. We hope to inspire the international community to adapt this innovative model to their own context of care.&#x0D; &#x0D;

Implementation and Evaluation of a Trainee Orientation Manual in an Intensive Care Unit Rotation.

The intensive care unit (ICU) rotation places trainees in a fast-paced, high-intensity environment that requires complex patient care and multidisciplinary coordination. Trainees seek continuous medical knowledge acquisition while tasked with learning ICU-specific workflows, procedures, and policies. The unfamiliarity with rotation logistics and administrative roles and expectations could hinder the ICU rotation learning experience. A lack of standardization and material for trainee orientation to administrative ICU tasks and workflows could affect the trainee's rotation performance and overall learner satisfaction. We evaluated the implementation of an ICU trainee manual to provide trainees with a source of orientation for rotation logistics and nonclinical ICU tasks. We assessd its impact on content retention, learners' satisfaction with the manual, and overall ICU rotation experience. We designed an observational, prospective cohort study that included all trainees scheduled to rotate in the ICU during the 2020-2021 academic year. The ICU manual was delivered electronically and was available throughout the academic year. Trainees received a survey before their first ICU rotation (pretest) and 6 months after their first ICU rotation (retest) to assess content retention, trainees' perception of the ICU manual, and overall rotation satisfaction. A total of 95 trainees completed the pretest survey, and 61 completed the retest survey. The target cohort response rate for each survey was 100%. Pretest scores were higher than the matched retest scores (41 of 48 [interquartile range, 37-44] vs. 38 of 48 [34-41]; P < 0.001). The median ICU manual satisfaction score was 32 of 40 (26-36.5). We found positive correlations between ICU manual trainee satisfaction score and the retest score (r[59] = 0.320; P = 0.01) and ICU rotation trainee satisfaction level (r[59] = 0.909; P < 0.001). Implementing an ICU manual to orient trainees to their ICU clinical rotation was well received and showed continued retention of orientation content. Higher ICU rotation trainee satisfaction levels were related to a positive perception of the ICU manual.

Advancing Care of Patients with Sickle Cell Disease through a Transformative Quality Improvement Initiative

Background Managing sickle cell disease (SCD) and its associated complications requires specialized knowledge often limited in primary and emergency care settings. Despite the availability of guideline recommendations and an expanding therapeutic landscape, hematologists experience challenges in managing sickle cell pain and implementing multidisciplinary care coordination that improves morbidity, overall disease management, and quality of life. To improve SCD care, we conducted a quality improvement (QI) study, bringing together healthcare professionals (HCPs) from established SCD centers to assess current practice patterns and develop strategies to overcome barriers to acute pain management and transitions of care for patients with SCD. Methods This QI initiative is comprised of baseline surveys (n = 115), pre- and post-surveys (n = 71) from the small-group, team-based audit-feedback (AF) sessions (Table 1), and 90-day follow-up surveys of HCPs from the four enrolled centers. Survey questions were designed to assess knowledge, confidence, and experiences managing acute pain, transitioning care, and keeping up with the latest clinical evidence and guideline recommendations for SCD. Care teams from each clinic, along with a nationally renowned expert SCD physician, participated in audit and feedback sessions to (a) assess system-specific practice gaps identified via the provider surveys, (b) prioritize areas for improvement, and (c) develop action plans for addressing root causes. Results Baseline surveys results revealed providers' top challenge encountered in managing patients with SCD as managing acute complications (40%) (Figure 1). Gaps were observed in clinicians reporting high/very high confidence in their ability to adequately manage SCD patients' acute pain episodes (51%), align clinical practices with evidence-based SCD guidelines (44%), and coordinate transitions of care (33%). Furthermore, baseline surveys showed only 19% of providers reported they are very/extremely satisfied with their current process for transitioning patients, noting top challenges in patient's difficulty navigating the adult healthcare system (47%) and deficiency of providers caring for patients with SCD near me (26%). Following participation in the AF sessions, clinicians indicated gains in high/very high confidence in their ability to adequately manage an acute pain episode for a patient with SCD (52% to 69%) and ability to coordinate transitions of care for patients with SCD (44% to 56%). During the AF sessions, Care teams set goals to improve provider education, appropriate acute care management of SCD and patient engagement. Action plans to achieve these goals include sharing the action plan with additional clinical team members (47%), collaborating among clinical teams to improve pain management plans for patients with SCD (39%) and improving patient education about SCD (31%). In 90-day follow up surveys, 75% of clinics reported improvements in acute pain management and transitions of care for patients with SCD. Furthermore, the top 3 areas of most improvement at the time of follow-up were enhancing sickle cell education provided to patients (75%), supporting teenage and young adult patients in independently managing their own care (50%), and coordinating meetings with local adult sickle cell providers and teenage/young adult patients and families (50%). Conclusions Through this QI initiative, clinical teams identified barriers to optimal SCD care, creating and implementing specific action plans to increasing knowledge of SCD and evidence-based therapies, optimizing transitions of care and improving acute pain management. While meaningful confidence and action plan gains were demonstrated, these data underscore clinical practice gaps to address in future initiatives to support safe, effective, and evidence-based processes for managing SCD to prevent complications and optimize outcomes and quality of life. Study Sponsor Statement The study reported in this abstract was funded by educational grants from Vertex Pharmaceuticals Incorporated and Agios Pharmaceuticals, Inc. The grantors had no role in the study design, execution, analysis, or reporting.