Multidisciplinary Patient Care Team Research Articles

PREECLAMPSIA COMPLICATED WITH PULMONARY EDEMA IN NEWLY DIAGNOSED PERIPARTUM DILATED CARDIOMYOPATHY: CASE REPORT

Objective: Pulmonary edema is one of the most serious complications of preeclampsia that should be ruled out in case of dyspnea in a pregnant woman. The prognosis is generally good, however it can indicate underlying unrecognized dilated cardiomyopathy. Design and method: We present a case of 30-year-old woman in 34 weeks of pregnancy was hospitalized at the Gynecology Clinic for preeclampsia. Results: This was the third pregnancy without any previous known cardiovascular disease or known hypertension. Cardiology examination was requested which showed conscious, severely dispnoic and tachycardic patient, with lower leg edema and bilateral pulmonary rales indicating acute pulmonary edema. Blood pressure was 170/100 mmHg, heart rate 130 bpm and saturation 89% with oxygen nasal mask. She reported the presence of headache. Patient was treated for three days with Metil dopa, Nifedipine and corticosteroid therapy of baby lung maturation. She received magnesium sulfate, Verapamil and intravenous Furosemide of 120 mg and the time of pulmonary edema. The patient was not in labor. The ultrasound revealed a monofetal pregnancy and amniotic fluid in normal quantity. Laboratory tests showed mild anemia with normal renal and liver function results. D-dimers were 1320 ng/ml. After stabilization of the patient, a C-section was performed, with the extraction of healthy newborn with an APGAR at 10/10th. There were no post-operative complications. There was marked disappearance of dyspnea within 72 hours, and stabilization of blood pressure. Patient was transferred to the cardiology clinic. Echocardiography showed signs of dilated cardiomyopathy with EF 30% and absent valvopathy. She was put on heart failure treatment with ACE inhibitor, beta blocker, MRA antagonist, furosemide, bromocriptine and LMWH. We received significant clinical improvement during the hospitalization. She was discharged after 6 days in NYHA class II. Conclusions: Acute pulmonary edema is a rare complication, but leading cause of death in women with pre-eclampsia. Diagnosis of peripartum cardiomyopathy requires heightened awareness among multidisciplinary patient care teams and a high degree of suspicion. Many patients with peripartum cardiomyopathy recover within 3 to 6 months of disease onset, but recovery might occur as late as 48 months postpartum

Implementing Rapid Whole-Genome Sequencing in Critical Care: A Qualitative Study of Facilitators and Barriers to New Technology Adoption

To characterize the views of members of the multi-disciplinary team regarding the implementation of rapid whole-genome sequencing (rWGS) as a first-tier test for critically ill children in diverse children's hospital settings. Qualitative interviews informed by implementation science theory were conducted with the multidisciplinary patient care teams and hospital leaders at each of the 5 tertiary care children's hospitals involved in a statewide rWGS implementation project. Our analysis revealed 5 key themes regarding the implementation process across the sites: the need for rWGS champions, educational needs and strategies, negotiating decision-making roles and processes, workflows and workarounds, and perceptions about rWGS. From the findings a composite clinical workflow diagram was developed to summarize all of the processes involved in the implementation of the test, and the key areas where implementation practices differed. These findings provide insights for design of interventions to support adoption, scale-up, and sustainability of rWGS and other novel technologies in neonatal and pediatric critical care settings.

Comment on Gross and MacDougall “Roles of the clinical pharmacist during the COVID‐19 pandemic”

The editorial by Gross and McDougall highlights the innovative roles that pharmacists have taken on during the COVID-19 pandemic.1 We aim to share our unique experience of multidisciplinary collaboration and adaptation of pharmacy practice within one of the nation's largest solid organ transplant (SOT) programs during the COVID-19 era. Recognizing the need to mitigate virus transmission, many team members, including our pharmacist, transitioned to working remotely. Following this change, our team swiftly initiated virtual rounding twice daily to improve communication between team members working onsite and remotely; multidisciplinary patient care discussions and team unity were preserved while maintaining social distance. During these virtual rounds, our pharmacist effectively made medication recommendations in order to ensure timely updates to patient care needs that required urgent intervention. This allowed our pharmacist and transplant coordinators to more efficiently work with the nurses and support staff onsite to schedule virtual patient education sessions. The COVID19 pandemic also required innovative means of continuing communication with our patients. SOT patients require thorough education on posttransplant medications and lifestyle choices. Our team transitioned these educational sessions to telemedicine education sessions. Meetings were arranged for the patients through institution owned iPads and caregivers could join the videoconference remotely. Before leaving the hospital, each of our patients received several hours of education with our pharmacist to assist their learning of medications, during which multiple teaching methods and tools were utilized. This communication method was also utilized for pretransplant patients when evaluating prior-to-admission medications and for readmitted patients to reinforce education. Several patients whose primary language was not English were also able to participate through multiprovider visits with simultaneous video interpretation. Other key members of our team including nurse practitioners transplant coordinators, and dieticians were able to learn from our pioneering experience and use this technology to safely and effectively communicate with our patients. SOT is a medical discipline that relies heavily on the collaboration of the interdisciplinary team. To maintain safety of our patients and team during the COVID-19 pandemic, we demonstrated ability to work together effectively in adapted roles. Through our innovative communication strategies, we have maintained exemplary patient care and outcomes. We will carry the lessons we learned through these challenges beyond the pandemic and continue to use them to ensure safe delivery of care. The authors declare no conflicts of interest.

Implementation of a "threat and error" model in complex neonatal cardiac surgery patients to identify quality improvement opportunities.

Neonates undergoing surgery for congenital heart disease are vulnerable to adverse events. Conventional quality improvement processes centring on mortality and significant morbidity leave a gap in the identification of systematic processes that, though not directly linked to an error, may still contribute to adverse outcomes. Implementation of a multidisciplinary "flight path" process for surgical patients may be used to identify modifiable threats and errors and generate action items, which may lead to quality improvement. A retrospective review of our neonatal "flight path" initiative was performed. Within 72 hours of a cardiac surgery, a meeting of the multidisciplinary patient care team occurs. A "flight path" is generated, graphically illustrating the patient's hospital course. Threats, errors, or unintended consequences are identified. Action items are generated, and a working group is formed to address the items. A patient's flight path is updated weekly until discharge. The errors and action items are logged into a database, which is analysed quarterly to identify trends. Thirty one patients underwent flight path review over a 1-year period; 22.5% (N=7) of patients had an error-free "flight." Eleven action items were generated - four from identified errors and seven from identified threats. Nine action items were completed. Flight path reviews of congenital cardiac patients can be generated with few resources and aid in the detection of quality improvement opportunities. The regular multidisciplinary meetings that occur as a part of the flight path review process can promote inter-professional teamwork.

Pharmaceutical interventions in the emergency department: cost-effectiveness and cost-benefit analysis

ObjectiveIt has been shown that pharmacists, as members of multidisciplinary patient care teams, can decrease the number of medicine errors. The objective of the present study was to analyse pharmaceutical...

Impact of an interprofessional medication error workshop on healthcare student perceptions

BackgroundThe integration of interprofessional education (IPE) into health professional curricula is critical to ensuring safe and efficient delivery of patient care. The intent of this manuscript is to describe the results of a pilot study designed to evaluate the impact of a large-scale interprofessional medication error prevention workshop on student perceptions of team-based patient care in the prevention of medication errors. Interprofessional education activityPharmacy, medical, and physician assistant students’ perceptions of the role of multidisciplinary patient care teams in preventing medication errors were evaluated before and after participating in a three-hour interprofessional medication errors prevention workshop utilizing a modified version of the validated Attitudes Towards Health Care Teams Scale. DiscussionWhen comparing student attitudes among the three schools, statistically significant differences in student perceptions across the items and subscales (e.g., quality of care/process and physician centrality) captured in the instrument utilized were identified. Additionally, differences in the responses of pharmacy, medical, and physician-assistant students were found, highlighting the areas where healthcare education can be targeted to bridge the gap in opinion. ImplicationsWe demonstrated an overall positive impact of an interprofessional medication errors prevention-themed workshop on the attitudes of the participating healthcare students. Future directions and research initiatives focusing on the role of IPE and the influence of IPE workshops on team-based performance are indicated to validate the influence of this method of education on the attitudes of post-graduate healthcare trainees and healthcare practitioners.

Pharmaceutical care of elderly patients with poorly controlled type 2 diabetes mellitus: a randomized controlled trial.

Care of the elderly with diabetes is more complicated than that for other age groups. The elderly and/or those with multiple comorbidities are often excluded from randomized controlled trials of treatments for diabetes. The heterogeneity of health status of the elderly also increases the difficulty in diabetes care; therefore, diabetes care for the elderly should be individualized. Motivated patients educated about diabetes benefit the most from collaborating with a multidisciplinary patient-care team. A pharmacist is an important team member by serving as an educator, coach, healthcare manager, and pharmaceutical care provider. To evaluate the effects of pharmaceutical care on glycemic control of ambulatory elderly patients with type 2 diabetes. A 421-bed district hospital in Nantou City, Taiwan. We conducted a randomized controlled clinical trial involving 100 patients with type 2 diabetes with poor glycemic control (HbA1c levels of ≥9.0 %) aged ≥65 years over 6 months. Participants were randomly assigned to a standard-care (control, n = 50) or pharmaceutical-care (intervention, n = 50) group. Pharmaceutical care was provided by a certified diabetes-educator pharmacist who identified and resolved drug-related problems and established a procedure for consultations pertaining to medication. The Mann–Whitney test was used to evaluate nonparametric quantitative data. Statistical significance was defined as P < 0.05. The change in the mean HbA1c level from the baseline to the next level within 6 months after recruiting. Nonparametric data (Mann–Whitney test) showed that the mean HbA1c level significantly decreased (0.83 %) after 6 months for the intervention group compared with an increase of 0.43 % for the control group (P ≤ 0.001). Medical expenses between groups did not significantly differ (−624.06 vs. −418.7, P = 0.767). There was no significant difference in hospitalization rates between groups. The pharmacist intervention program provided pharmaceutical services that improved long-term, safe control of blood sugar levels for ambulatory elderly patients with diabetes and did not increase medical expenses.

Endocrine disorders in Fanconi anemia: recommendations for screening and treatment.

Endocrine problems are common in patients with Fanconi anemia (FA). About 80% of children and adults with FA have at least one endocrine abnormality, including short stature, GH deficiency, abnormal glucose or insulin metabolism, dyslipidemia, hypothyroidism, pubertal delay, hypogonadism, or impaired fertility. The goal of this report is to provide an overview of endocrine abnormalities and guidelines for routine screening and treatment to allow early diagnosis and timely intervention. This work is based on a comprehensive literature review, including relevant articles published between 1971 and 2014, and proceedings of a Consensus Conference held by the Fanconi Anemia Research Fund in 2013. The panel of experts collected published evidence and discussed its relevance to reflect current information about the endocrine care of children and adults with FA before the Consensus Conference and through subsequent deliberations that led to the consensus. Individuals with FA should be routinely screened for endocrine abnormalities, including evaluation of growth; glucose, insulin, and lipid metabolism; thyroid function; puberty; gonadal function; and bone mineral metabolism. Inclusion of an endocrinologist as part of the multidisciplinary patient care team is key to providing comprehensive care for patients with FA.

Nurse-directed catheter removal protocols to prevent catheter-associated urinary tract infection: Strategies for implementation

The translation of evidence-based practices to the bedside requires flexibility to change traditional ways of practice. The paradigm shift of responsibility for reducing health careeassociated infections (HAIs) from the infection control professionals to the multidisciplinary patient care team has facilitated the adoption of interventions, with evidence suggesting a clinical benefit. This shift in accountability to clinicians has led to the implementation of HAI prevention strategies that are timely, sustainable, and successful. Recent publications on reducing unnecessary urinary catheter use illustrate the impact that team-led initiatives can achieve by leveraging technology and the quality improvement methodology of rapid-cycle change and implementation science.

What Radiologists Need to Know about Diagnosis and Treatment of Inflammatory Breast Cancer: A Multidisciplinary Approach

Inflammatory breast cancer (IBC) is a rare breast cancer with a highly virulent course and low 5-year survival rate. Trimodality treatment that includes preoperative chemotherapy, mastectomy, and radiation therapy is the therapeutic mainstay and has been shown to improve prognosis. Proper diagnosis and staging of IBC is critical to treatment planning and requires a multidisciplinary approach that includes imaging. Patients with IBC typically present with rapid onset of breast erythema, edema, and peau d'orange. Both tissue diagnosis of malignancy and clinical findings of inflammatory disease are required to confirm diagnosis of IBC. Imaging is used to identify a biopsy target; direct biopsy; stage IBC; differentiate curable from incurable (stage IV) disease; and help plan chemotherapy, surgical management, and radiation therapy. Comparison of baseline and posttreatment images helps confirm and quantitate disease response. When imaging is used early in the course of therapy to noninvasively predict treatment response, optimal tailored strategies for management of IBC can be implemented. Imaging is vital to diagnosis and treatment planning for patients with IBC, and radiologists are an integral part of the multidisciplinary patient care team.

Spirometry: Tool for pharmacy practitioners to expand direct patient care services

ObjectivesTo introduce pharmacy practitioners to spirometry testing and provide strategies for integrating this “value-added” tool with other direct patient care pharmacy services. Data sourcesSpirometry literature and resources obtained through search strategies including Ovid, PubMed, and Google Scholar. SummaryPharmacists are distinctive members of the multidisciplinary patient care team and can contribute by performing spirometry services for pulmonary patients. Pharmacists have been largely absent from performing this much needed service, perhaps as a result of lack of training or because this testing may be perceived as irrelevant to the pharmacist scope of practice. However, pharmacists are actively integrated with many aspects of pulmonary patient care, including recommending and adjusting inhaled pharmacological agents, monitoring for potential drug–drug and drug–disease interactions, recommending smoking cessation, assessing patient prescription insurance coverage, and educating patients, caregivers, and health care providers on use of prescribed respiratory delivery devices. Adding quality spirometry services, based on American Thoracic Society guidelines for accuracy, would increase the breadth and depth of services for pharmacy practitioners. ConclusionSpirometry testing is an added tool for expanding direct patient care pharmacy services. Physician support, appropriate pharmacist training, and understanding of reimbursement of spirometry services are essential in providing quality spirometry testing. Future studies are needed to assess the role of pharmacists in performing spirometry and measuring the performance outcomes of pulmonary patients.

CPC-082 Measuring Effectivity: Pharmaceutical Interventions Through Computerised Physician Order Entry Versus Direct Phone Calls

BackgroundComputerized physician order entry (CPOE) implementation in hospitals has become an important tool for interactive validation of medical orders as well as a facilitator for pharmacist interventions. However several studies...

Creating a culture of safety within operative neurosurgery: the design and implementation of a perioperative safety video

Surgical and medical errors result from failures in communication and handoffs as well as lack of standardization in clinical protocols and safety practices. Checklists, simulation training, and teamwork training have been shown to decrease adverse patient events and increase the safety culture of surgical teams. The goal of this project was to simplify and standardize perioperative patient safety practices and team communication processes within operative neurosurgery through the creation of an educational safety video targeted at a neurosurgical provider audience. A multidisciplinary group consisting of neurosurgeons, anesthesiologists, nurses, neuromonitoring specialists, quality champions, and a professional video production company met over several months in an iterative process to 1) determine the overall objectives of the video, 2) decide on the content and format of the video, 3) modify the proposed content and format based on stakeholder feedback, and 4) record the video and complete final revisions during postproduction. The video was launched within the authors' institution in July 2012 in conjunction with ongoing research projects to study the effects of the video on 1) multidisciplinary providers' knowledge of perioperative safety practices, 2) provider safety attitudes and safety culture in the operating room, and 3) provider behavior in performing predetermined elements of the preoperative timeout and postoperative debrief. The neurosurgical perioperative safety video can serve as a national model for how quality champions can drive changes in safety culture and provider behavior among multidisciplinary perioperative patient care teams. Ongoing research is being performed to assess the impact of the video on provider knowledge, behavior, and safety attitudes and culture.

The clinical pharmacist’s contributions within the multidisciplinary patient care team of an intern nephrology ward

To describe and evaluate newly implemented clinical pharmacy services and ward round participation on a specialized nephrology ward in a large tertiary care hospital. All issues addressed by the clinical pharmacist were systematically collected, and the contributions were classified by type. Where applicable, physicians' acceptance rates were recorded. The drugs most commonly affected by the clinical pharmacist's contributions are described. A total of 158 clinical pharmacist's contributions were recorded. Approximately 90% (n = 104) of applicable suggestions (117 out of 158; 74%) were accepted by the treating physicians. Most issues were discussed with physicians (85%); the remaining issues were discussed with nurses and medical students. Antimicrobials, drugs affecting the alimentary system and metabolism, and cardiovascular drugs were among the most commonly affected drugs. Issues concerning dosage and drug-therapy selection were common. The clinical pharmacist was also involved in developing dosing guidelines and performing literature searches. The observed effects of a newly implemented clinical pharmacy service on an internal nephrology ward are encouraging; acceptance rates of suggestions and the multidisciplinary appreciation of clinical pharmacy services are high.

Collaborative information seeking: A field study of a multidisciplinary patient care team

Multidisciplinary teams are an essential aspect of modern organizational work. These teams often work in information-rich environments but little is known about their collaborative information seeking (CIS) behavior. We have been studying the CIS behavior of teams in the context of medical care. We conducted an ethnographic field study of a multidisciplinary patient care team in an emergency department to identify (a) team information needs and (b) situations that trigger collaborative information seeking activities. We identified seven categories of information needs as expressed by questions asked by team members. The majority of questions focused on medical information, but there were a larger than expected percentage of questions focusing on organizational information. We also identified three triggers for CIS activities. These triggers are: (1) lack of expertise, (2) lack of immediately accessible information, and (3) complex information needs. The questions and triggers highlight the importance of face-to-face communication during CIS activities and how CIS activities could lead to interruptive workplaces. We also discuss organizational and technical implications for supporting CIS behavior of teams.

Coping with methodological dilemmas; about establishing the effectiveness of interventions in routine medical practice.

BackgroundThe aim of this paper is to show how researchers balance between scientific rigour and localisation in conducting pragmatic trial research. Our case is the Quattro Study, a pragmatic trial on the effectiveness of multidisciplinary patient care teams used in primary health care centres in deprived neighbourhoods of two major cities in the Netherlands for intensified secondary prevention of cardiovascular diseases.MethodsFor this study an ethnographic design was used. We observed and interviewed the researchers and the practice nurses. All gathered research documents, transcribed observations and interviews were analysed thematically.ResultsConducting a pragmatic trial is a continuous balancing act between meeting methodological demands and implementing a complex intervention in routine primary health care. As an effect, the research design had to be adjusted pragmatically several times and the intervention that was meant to be tailor-made became a rather stringent procedure.ConclusionA pragmatic trial research is a dynamic process that, in order to be able to assess the validity and reliability of any effects of interventions must also have a continuous process of methodological and practical reflection. Ethnographic analysis, as we show, is therefore of complementary value.

Configured for innovation: the case of palliative care

PurposeTo begin a process of understanding how palliative care organisations are configured to enable innovative multidisciplinary patient care teams and their management in an uncertain, complex and dynamic environment.Design/methodology/approachA range of literature was reviewed to suggest configuration and characteristics that were tested using semi‐structured interviews with the senior medical staff member at each of three Australian case study organisations. Data gathered from these interviews was supplemented with data gathered from semi‐structured interviews with multidisciplinary management teams and patient care teams dealing with inpatients and home‐care patients.FindingsA hybrid configuration is suggested, based on Mintzberg's typology of organisations. Responses from interviews modify some characteristics of the suggested configuration, though generally appearing to support it. Characteristics of the external and internal environments are described.Research limitations/implicationsPalliative care is rarely written off outside the healthcare literature and comparatively infrequently within it. Configuration is used to suggest the characteristics of innovative teams in an uncertain, dynamic, complex environment. The use and management of multidisciplinary patient care teams in palliative care offers interesting insights for a broad range of organisations.Practical implicationsA contribution to the discourse on the relationship between configuration and innovation based in organisations without commercial imperative, delivering multi‐level care for and by people involved in the end‐of‐life process.Originality/valueThe paper continues a line of publications, beginning in 2002, describing the management of innovation in multidisciplinary palliative care teams. The originality and value of this paper and this line of research is in taking a management view of a unique environment that offers insights and lessons to a broad range of organisations.

Integrated care programmes for chronically ill patients: a review of systematic reviews

To investigate effectiveness, definitions, and components of integrated care programmes for chronically ill patients on the basis of systematic reviews. Literature review from January 1996 to May 2004. Definitions and components of integrated care programmes and all effects reported on the quality of care. Searches in the Medline and Cochrane databases identified 13 systematic reviews of integrated care programmes for chronically ill patients. Despite considerable heterogeneity in interventions, patient populations, and processes and outcomes of care, integrated care programmes seemed to have positive effects on the quality of patient care. No consistent definitions were present for the management of patients with chronic illnesses. In all the reviews the aims of integrated care programmes were very similar, namely reducing fragmentation and improving continuity and coordination of care, but the focus and content of the programmes differed widely. The most common components of integrated care programmes were self-management support and patient education, often combined with structured clinical follow-up and case management; a multidisciplinary patient care team; multidisciplinary clinical pathways and feedback, reminders, and education for professionals. Integrated care programmes seemed to have positive effects on the quality of care. However, integrated care programmes have widely varying definitions and components and failure to recognize these variations leads to inappropriate conclusions about the effectiveness of these programmes and to inappropriate application of research results. To compare programmes and better understand the (cost) effectiveness of the programmes, consistent definitions must be used and component interventions must be well described.

Palliative care teams and management levers

This paper is the third in a series that will examine the management of innovation by multidisciplinary patient care teams in palliative care in Australia and reports on the existence and use of organisational levers to enable and influence required characteristic behaviours in the teams. These levers work in concert with organisational capabilities to resource the required behaviours. Interviews with management teams in three Australian palliative care case study organisations confirm the existence and use of organisational levers. It appears that levers are available organisationally and utilised where necessary but fall into three distinct groups, those utilised by any person or group needing them, those utilised more specifically by management teams and those utilised by multidisciplinary patient care teams. It is noted that these groups are dependent on the existence of the levers for the optimisation of their efforts.

Palliative care teams and individual behaviours

This paper is the second in a series that will examine the management of innovation by cross‐functional, multidisciplinary patient care teams in palliative care. Two further outcomes of this research are reported here. The first is that within palliative care a number of distinct individual behaviours are identified that act as foundations for the successful development and application of innovative practices by multidisciplinary teams. The second is that interviews with multidisciplinary palliative care teams in case studies in Australia confirm the existence and use of these behaviours. Individual behaviours within these teams are found to fall into two groups: those used by palliative care professionals when working with patients and patient‐based carers; and those used by professionals when dealing with each other away from patients. The purpose of both groups is to generate useful valid information, knowledge and learning that can be transferred across boundaries regardless of boundary type or location.