Multidisciplinary Education Program Research Articles

Impact of Predialysis Care on Clinical Outcomes

A structured predialysis multidisciplinary team program is beneficial in improving quality of life in patients with end-stage renal disease (ESRD). Educating pre-ESRD patients about their disease is vital in their care. Patients who can identify signs and symptoms of impending problems can seek help and avoid complications that may lead to hospital admissions. Our dialysis center offers two predialysis classes in a structured format. The first class is for those patients with mild to moderate renal disease, whereas the second class is for those with advanced renal disease who are expected to need dialysis in 3 to 6 months. The patients are followed by a multidisciplinary team once they are enrolled in our chronic kidney disease program. We retrospectively reviewed all the charts of patients who started dialysis at our center between 1997 and 2000. We identified 68 patients who participated in the predialysis education program and 35 patients who did not because of late referral or refusal to participate. We compared these two groups over a 100-day period (10 days before initial dialysis and 90 days after), for hospitalizations, emergency room (ER) visits, and dialysis access placement. Patients' comorbid conditions, complications, and length of hospitalizations were extracted from the medical records. The 68 patients who completed the predialysis program had an average age of 60.3 years, a total of 96 hospital days, and 39 ER visits. Average length of hospital stay for these patients was 1.4 days. Three patients (4.4%) required placement of temporary catheters for the initial dialysis. Fifty-one percent of these patients had diabetes mellitus. The 35 patients of average age of 54.9 years who did not go through the program had 347 total hospital days and 39 ER visits. Average length of hospitalization was 9.9 days. Thirteen patients (37%) required temporary catheters for initial dialysis. This group included 16 patients (45.7%) with diabetes. Patients who participated in a multidisciplinary predialysis education program had fewer complications, ER visits, and hospitalizations. They also had fewer temporary catheter placements, shorter hospital stays, and reduced costs associated with initial dialysis.

Pulmonary rehabilitation

Pulmonary rehabilitation is a multidisciplinary education and exercise programme of care for patients with chronic respiratory disease, particularly Chronic Obstructive Pulmonary Disease (COPD). It aims to reduce symptoms, decrease disability, increase participation in physical and social activities and improve overall quality of life in patients who may still be very disabled despite optimal pharmacological treatment. Pulmonary rehabilitation first began more than 30 years ago and is now established as an important part of the management of COPD.

Pharmacist involvement in a multidisciplinary inpatient medication education program.

The development of a multidisciplinary inpatient medication education program is described. A multidisciplinary group designed and implemented a medication education program with defined roles for both nurses and pharmacists. Nurses provided medication education to patients during each medication administration using specially designed assessment and teaching tools. The nursing staff submitted requests for pharmacist consultations for patients with complex medication regimens, who were admitted because of a drug-related problem or who required additional teaching as determined through the medication education assessment form. A complex medication regimen was defined as the administration of oral medication more than five different times per day, the start of at least 5 new medications that would be continued at discharge, or the prescribing of at least 10 medications to be taken daily that would be continued at discharge. Pharmacists provided education for 19% of admitted patients during a six-month period. As a result of pharmacists' interactions with prescribers and nurses, the number of medications was reduced in 12% of these patients, and the number of medication administrations each day was reduced in 19% of patients. In addition, for 33% of patients, pharmacists contacted the prescriber to make recommendations beyond the scope of the medication education program that optimized and simplified the patient's drug regimen. The development of a structured medication education program allowed patients to receive medication education throughout their hospitalization from both nurses and pharmacists. Pharmacists provided education for patients at highest risk for noncompliance or poor outcomes. Full implementation of a medication education program involving staff pharmacists is planned.

A MULTIDISCIPLINARY BEHAVIOR ORIENTED PROGRAM POSITIVELY AFFECTS MORPHOLOGIC, PSYCHOMETRIC, AND CLINICAL PROFILES IN OBESE ADULTS

The degree to which the negative profile of the obese can be redressed through behavior education about lifestyle decisions is not clear. PURPOSE To assess the effectiveness of an individualized, clinic-based, multidisciplinary behavior education program, on the morphologic, psychometric, and clinical status of the obese. METHODS High-risk obese individuals (n = 19; BMI = 45.9kg/m2) completed a 12-week clinic-based lifestyle-oriented program (LP) followed by a 12-month maintenance program (MP). Risk factors presented included hypertension, hyperlipidemia, diabetes Type 2, and depression. The program incorporated individual clinic sessions on nutrition education, behavioral counseling, exercise prescription, and physician assessment. RESULTS The following relative changes were observed. Morphologic: At the end of LP (vs initial): BMI −4.1 %, weight −5.1%, fat% −6.2% (all p < 0.05). At the end of MP (vs initial): BMI −6.54%, weight −8%, fat% −10.4% (all p < 0.05). Psychometric: Depression (Beck's Index) decreased by 72.4% (p < 0.05) and remained constant throughout MP. Self-esteem (Rosenberg's scale) increased by 9.9% (LP vs initial) and remained constant for MP. Clinical: Of the patients exhibiting depression (n = 5), 40% discontinued medication and 40% avoided medication altogether. Of the diabetic patients (n = 6), 33% avoided medication, 33% reduced medication dependency by > 50%, while the remainder improved glucose control. Of patients exhibiting hypertension (n = 12), 33% reduced medication levels, 42% avoided or discontinued medications entirely, while 25% improved control. Of patients presenting hypercholesterolemia (n = 11) 82% avoided or discontinued medications. CONCLUSION These results suggest that an individualized, clinic supported multifaceted education program, can effectively improve the morphological status concurrent with reductions in existing or projected risk for diabetes, hypertension, and other lifestyle oriented diseases in obese adults.

Diabetes rehabilitation: development and first results of a Multidisciplinary Intensive Education Program for patients with prolonged self-management difficulties

For a number of diabetes patients regular care may be insufficient. A Multidisciplinary Intensive Education Program (MIEP), based on the empowerment approach, has been developed to help patients obtain their treatment goals (adequate self-management, glycemic control and quality of life). The aim of this pilot study is to determine the effects of MIEP and it’s mechanisms of influence. MIEP consisted of 12 days group-sessions and individual counseling. At baseline and 3-months follow-up, blood-glucose (HbA 1c), quality of life, health locus of control, distress, and knowledge were obtained ( N=51). Paired T-tests and regression analyses were conducted. HbA 1c and knowledge improved significantly, patients rated themselves healthier and were more internal and less powerful others oriented. Baseline scores explained effects in HbA 1c and quality of life. Locus of control significantly contributed in effects on quality of life. MIEP benefited patients with prolonged self-management difficulties, and this form of care seems to complement regular care.

Fall management and prevention: a day hospital perspective

The aim of this pilot project was to establish and evaluate a multidisciplinary health promotion and education programme aimed at preventing falls in the elderly. The overall objective was to plan and provide a scheme based on therapy, rehabilitation and health education.

Regional chemotherapy is indicated after surgical resection of colorectal metastases to the liver: a debate.

Surgical resection for selected patients with hepatic metastases from colorectal cancer can cure approximately one-fourth of these patients. The addition of regional chemotherapy as an attempt to improve this statistic has been extensively investigated in clinical trials. As part of a multidisciplinary educational program, a series of debates on various topics in oncology are held at the Roswell Park Cancer Institute, Buffalo, New York, involving the medical, surgical, and radiation oncology departments. One such debate focused on the use of regional chemotherapy after potentially curative resection of hepatic metastases from colorectal cancer. The representative medical and surgical oncology fellows (N.I.K. and B.P.M.), with guidance from their respective mentors (C.G.L., J.F.G., and N.J.P.), presented concise reviews from the literature arguing for and against the use of regional chemotherapy in this setting. They appear as Parts 1 and 2 in this article. This exercise is purely educational and does not in any way reflect the opinion or the clinical practice of the authors. .

Eliminating intensive postoperative care in same-day surgery patients using short-acting anesthetics.

A multidisciplinary effort was undertaken to determine whether patients could safely bypass the postanesthesia care unit (PACU) after same-day surgery by moving to an earlier time point evaluation of recovery criteria. A prospective, outcomes research study with a baseline month, an intervention month, and a follow-up month was designed. Five surgical centers (three community-based hospitals and two freestanding ambulatory surgical centers) were utilized. Two thousand five hundred eight patients were involved in the baseline period, and 2,354 were involved in the follow-up period. Outcome measures included PACU bypass rates and adverse events. Intervention consisted of a multidisciplinary educational program and routine feedback reports. The overall PACU bypass rate (58%) was significantly different from baseline (15.9%, P < 0.001), for patients to whom a general anesthetic was administered (0.4-31.8%, P < 0.001), and for those given other anesthetic techniques (monitored anesthesia care, regional or local anesthetics; 29.1-84.2%, P < 0.001). During the follow-up period, the average (SD) recovery duration for patients who bypassed the PACU was significantly shorter compared to that for patients who did not bypass, 84.6 (61.5) versus 175.1 (98.8) min, P < 0.001, with no change in patient outcome. Patients receiving only short-acting anesthetics were 78% more likely (P < 0.002) to bypass the PACU after adjusting for various surgical procedures. This study represents a substantial change in clinical practice in the perioperative setting. Same-day surgical patients given short-acting anesthetic agents and who are awake, alert, and mobile requiring no parenteral pain medications and with no bleeding or nausea at the end of an operative procedure can safely bypass the PACU.

An osteoporosis clinical pathway for the medical management of patients with low-trauma fracture.

Patients with an osteoporotic fracture have at least a 2-fold risk for additional fracture and should benefit from targeted diagnostic and treatment procedures for osteoporosis. To address this issue, we set up an osteoporosis clinical pathway (OCP) for the medical management of patients with low-trauma fracture. Following acute management of the fracture by the orthopedic team, patients are enrolled in the pathway, which is based on an interaction between the OCP multidisciplinary team, orthopedic surgeons and/or primary care physicians. After collection of patient data, suggestions for additional diagnostic examinations with their interpretation, and treatment proposals are made. Patients and their families are also invited to attend a multidisciplinary interactive educational program on physical therapy, lifestyle habits and nutrition. During a 36-month period, 385 patients (311 women, 74 men; mean age +/- SD: 73.0 +/- 13.5 years; hip fracture 45%, ankle/tibia 24%, proximal humerus 8.6%, spine 5.5%, pelvis 3.9%, distal forearm 3.6%, other sites 17.4%) were enrolled in the OCP. An osteoporosis awareness questionnaire administered within 10 days of fracture showed that 73% of patients believed that their fracture was not related to the disease. Dual-energy X-ray absorptiometry, performed in 63% of patients, showed that 86% had low bone mass or osteoporosis. Specific antiosteoporotic therapy was proposed for 33% of patients in addition to calcium and vitamin D supplements, the latter suggested for 93%. A survey performed in 216 patients 6 months later, indicated that 63% of the suggested treatments had been prescribed and that 67% of this group were continuing treatment. Such a clinical pathway for the medical management of low-trauma fracture can help to identify patients with osteoporosis in a high-risk population, provide support to the orthopedic surgeon and/or the primary care physician for diagnostic and treatment procedures, and should significantly contribute to increase awareness of the disease in patients and their families.

Rehabilitation approaches to stroke.

This article describes the state of the science in stroke rehabilitation dealing with three main topics: (1) General approach to stroke rehabilitation (stroke services and stroke units), (2) Neurophysiological and pharmacological interventions (facilitation of brain repair mechanisms) and (3) Experimental approaches (neuronal transplantation). Stroke rehabilitation is an active process beginning during acute hospitalisation, progressing to a systematic program of rehabilitation services and continuing after the individual returns to the community. There is world-wide consensus that stroke patients should be treated at specialised stroke unit with specially trained medical and nursing staff, co-ordinated multidisciplinary rehabilitation and education programs for patients and their families. Stroke Unit has been shown to be associated with a long-term reduction of death and of the combined poor outcomes of death and dependency, independent of patients age, sex, or variations in stroke unit organisations. No study has clearly shown to what extent the beneficial effect is due to specific rehabilitation strategies. New imaging studies in stroke patients indicate altered post stroke activation patterns, which suggest some functional reorganisation. Reorganisation may be the principle process responsible for recovery after stroke. It is assumed that different post ischaemic interventions like physiotherapy, occupational therapy, speech therapy, electrical stimulation, etc. facilitates such changes. Scientific evidence demonstrating the values of specific rehabilitation interventions after stroke is limited. Comparisons between different methods in current use have so far mostly failed to show that any particular physiotherapy, occupational therapy, speech therapy or stroke rehabilitation strategy is superior to another. Clinical data are strongly in favour of early mobilisation and training. Pharmacological interventions in animals revealed that norepinephrine, amphetamine and other alpha-adrenergic stimulating drugs can enhance motor performance after unilateral ablation of the sensory motor cortex. The clinical data in humans are rather contradictory. Neural grafting and neurogenesis are new potential modes of stroke therapy. Neural grafting enhanced functional outcome and reduced thalamic atrophy in rats only when combined with housing in enriched environments. Recent studies have shown that stem cells can differentiate to neurons in the adult human dentate gyrus in vivo.

Multidisciplinary education and management program for children with asthma

A multidisciplinary program for managing asthma in a pediatric population is discussed. A coordinated, multidisciplinary program for managing asthma in children was initiated in November 1997 at a U.S. Army medical center. The program, designed to improve care and decrease hospitalizations for asthma, was pharmacist managed and pulmonologist directed and was implemented by pediatricians. Patient education was provided by a pediatric clinical pharmacist or a nurse case manager; providers also received intensive education. Follow-up occurred at predetermined intervals and included asthma education, discussion of expectations and goals, analysis of metered-dose-inhaler and spacer technique, and assessment of compliance. Between November 1997 and January 1999, 210 inpatients were screened for asthma. One hundred seven were believed to have asthma and received inpatient asthma counseling and teaching. Of these 107 patients, 79 were enrolled in the program and monitored in the ambulatory care setting. Seventy-one (90%) of the 79 program enrollees were not rehospitalized during the ensuing two years. The number of children admitted to the hospital for asthma decreased from 147 in 1997 (a rate of 3.2 per 1000 population) to 93 in 1998 (2.1 per 1000) and to 87 in 1999 (1.9 per 1000). A multidisciplinary approach to the management of children with asthma may reduce hospitalizations of such patients.

Insulin Medication Error Reduction: A Quality Improvement Initiative

This study describes a multidisciplinary approach to reducing insulin medication errors. In 1998, a medication error analysis at our institution demonstrated that insulin was the top drug associated with medication errors. A collaborative continuous quality improvement initiative was undertaken to develop recommendations for reducing insulin medication errors. Multidisciplinary root cause analysis revealed that during order prescribing and transcribing, the abbreviation of “u” for units—combined with the lack of a formal education program for physicians on appropriate use of abbreviations—was a major contributing cause to insulin medication errors. An extensive multidisciplinary education program was undertaken to target insulin orders for medication error reduction. To date, compliance with prescribing insulin orders within guidelines has increased from 30% to 74%, and compliance with transcribing insulin orders within guidelines has increased from 36% to 83%. This collaborative project increased awareness of insulin medication error causation and will be used as a template to reduce other types of medication errors.

Quality of Medication Ordering at a Large Teaching Hospital

Objectives: To identify and quantify deficiencies in the prescribing/ordering of inpatient and discharge medications and determine strategies to address them.Design and setting: A descriptive study in medical and surgical wards at a tertiary referral teaching hospital.Patients: All available inpatients in 12 medical and 2 surgical wards on two consecutive days and all discharges on a single day.Results: Medication orders for 230 inpatients and 68 discharge patients were audited. A total of 2978 inpatient orders were reviewed including 634 ‘once only’ doses, 1840 regular and 504 ‘as required’ medications. Errors in physician prescribing occurred at a frequency of 25/1000 prescriptions and included 48 (1.6%) incorrect, ambiguous or unspecified doses and four prescriptions where the specific oral form was not stated. In 14 (0.5%) cases, the dosing frequency specified was wrong, unclear or absent and there were three cases of duplication. Two patients were prescribed drugs to which they had a documented allergy. Details of previous adverse drug reactions were complete in only 14 of 62 (23%) patients. Of the 68 discharge prescriptions audited, orders for 49 of 329 regular medications (15%) had been unintentionally omitted (range 1‐8 medications per patient).Conclusions: The audit identified limitations in the quality of prescribing/ordering which were in part due to deficiencies in the current medication chart and discharge summary. To address these limitations, the medication ordering system has been revised and a multidisciplinary educational program implemented to promote safe and explicit prescribing.

Internet program development leading to certification in substance abuse prevention

The purpose of this project was to develop a multidisciplinary educational program that would provide information needed to work more efficiently in substance abuse prevention and prepare the learner for certification examination. Because prevention service providers are scattered throughout the state, country, and global community, an educational program had to be easily accessible. The solution was to develop a web‐based curriculum that could be accessed anywhere in the world. One that would meet not only state requirements, but also would conform to international certification criteria. Qualitative analysis was used to categorize broad content areas of university course offerings, core functions considered vital by the state, and various educational programs in substance abuse throughout the country. As themes and subthemes emerged, clusters of essential components were retrieved and divided into four groupings. These groupings later translated into four distinct modules, each containing four to six components of study. A pilot group of 17 people were recruited throughout the state. These service providers took the web‐based program over a period of 3 months and then participated in a special administration of an international certification exam. Results showed a 94% pass rate for the pilot group as compared with a national 32 %.

Mental Quality of Life

ABSTRACT This exploratory study investigates the quality of life needs of 173 individuals being treated for type 2 diabetes over a six month period of time. It samples patients whose primary care providers practice the most current model for delivering care, diabetes disease management. These physicians utilized a multidisciplinary diabetes education program to facilitate the patient-provider knowledge-based partnership essential in disease management. Patient quality of life changes were measured by the SF-36. A paired samples t-test showed significant diminishment in patients' mental quality of life indicating diminished overall emotional functioning, negatively impacting quality of life; possibly due to the effects of time. Multiple regression results also indicated that patients at risk for major depression and at risk for major depression superimposed on dysthymia experienced significantly diminished mental quality of life. These findings suggest that enhanced mental health assessment and mental health services provided by social workers in diabetes education programs and/or primary care settings would improve patient mental quality of life.

A Multimodal Education and Treatment Program for Young Adults with Atopic Dermatitis: A Randomized Controlled Trial

Background: Atopic dermatitis (AD) is a chronic skin disorder with multifactorial etiology and with high medical, psychological, social, and financial impact. The aim of treatment is coping with this disease rather than cure. Adequate coping implies knowledge of the multifactorial etiology including psychological factors, compliance with dermatological treatment, and adjustment to the consequences of this chronic condition in daily life. Education and training should improve self-management and reduce dependency on medical consultation. Objective: To describe and evaluate a multimodal, psychoeducational and dermatological treatment program for young adults with atopic dermatitis. Methods: A multimodal treatment program was developed: a 2-week intensive multidisciplinary education and training program for small groups. Patients aged 18–35 years with moderate to severe AD (SCORAD > 20) were randomly assigned to the treatment program group (n = 31) and a control group (n = 22); 2 patients of the control group dropped out. Baseline assessment took place before treatment. Short-term effects were measured after 10 weeks, long-term effects after 40 weeks. Patients in the control group received standard care. Primary outcome measures were: the total score on the Marburg AD questionnaire, sick leave, and medical consultations. Secondary outcome measures were: quality of life (SF-36), appraisal of self-care, use of emollients, and SCORAD. Results: The experimental group scored significantly better on the Marburg AD questionnaire after treatment (short term and long term). At follow-up after 40 weeks, the experimental group scored better on appraisal of self-care, needed less time for medical consultations, and used more emollients without steroids. Sick leave was less after 10 weeks, but equalized at follow-up. Patient satisfaction with the multimodal treatment program was high. Conclusions: The results of this pilot study suggest that the treatment program is successful in improving self-management of patients; they perceive more control over their chronic disease, and interactions with their doctors are more efficient and more satisfying for both patients and doctors.

Development and Implementation of a Multidisciplinary Anticoagulation Educational Program

Staff development programs have been developed by national pharmacy organizations to improve clinical skills and expand the services offered by pharmacists. Most of these programs do not involve the training of other health care professionals. This article describes an anticoagulation training program designed not only for pharmacists, but for physicians and nurses as well. For pharmacists, the effectiveness of educational interventions was assessed by pretest/post-test/surveys with an average increase of 38% from baseline (p &lt; 0.01). The knowledge gained by physicians and nurses is an ongoing process evaluated by follow-up warfarin medication use evaluations and prospective weight-based heparin protocol evaluations. The goal of staff development should be to equip each member of the health care team with the knowledge needed to improve patient outcomes.

The Phil Hearne course: an evaluation of a multidisciplinary mental health education programme for clinical practitioners.

A description and evaluation of the pilot of a 30-week multidisciplinary mental health education programme (The Phil Hearne Course) is presented. The course was based upon the expressed service needs of an NHS Trust and upon the needs of users consulted during the developmental phase of the project. The course was designed to provide core skills, relating to effective assessment, communication, intervention and networking. These skills were thought to be applicable to all mental health disciplines. The course was evaluated positively by students and staff and was found to be effective in improving practice by providing a range of core skills for mental health workers. It was also determined that students tended to over-estimate their skills in core areas, particularly care planning and record-keeping. It is intended to develop the course into a distance learning, skills-based package.

Educating Community Providers ChangesBeliefs Towards Caring for the ESRD Patient

End-Stage Renal Disease (ESRD) patients often have comorbid conditions necessitating the involvement of multiple professionals from various settings such as dialysis centers, primary care and skilled nursing facilities, group homes, mental health, rehabilitation, and home health care agencies. This provision of services can be fragmented and may be impeded by a lack of knowledge regarding the specific needs of renal patients. "A Caring Community: An Integrated Approach to Meeting the Needs of the Renal Patient" is a multidisciplinary professional education program which has been shown to change the beliefs of community providers regarding ESRD patients. Program attendee survey responses were measured in accordance with a modified Health Belief Model. This report identifies the need and demand for interdisciplinary renal education and the potential benefits of such a community-wide intervention and makes recommendations for future research.

Ocular manifestations of diabetes mellitus.

The ocular complications of diabetes mellitus are numerous and include retinopathy, cataract, uveitis, and neurophthalmic disorders. A review of the current literature shows that the emphasis has changed from the laser and surgical management of pre-existent retinopathy to the development of cohesive multidisciplinary screening and education programs, and to a better understanding of the cellular and molecular mechanisms that underlie disease. The role of associated and potentially modifiable systemic factors is also now recognized. Early intervention with systemic and local therapies may soon provide hope for the better management of diabetic eye disease.