Multistage Intervention Research Articles

Cost-effectiveness of a patient-reported outcome-based remote monitoring and alert intervention for early detection of critical recovery after joint replacement: A randomised controlled trial.

While the effectiveness of patient-reported outcome measures (PROMs) as an intervention to impact patient pathways has been established for cancer care, it is unknown for other indications. We assessed the cost-effectiveness of a PROM-based monitoring and alert intervention for early detection of critical recovery paths following hip and knee replacement. The cost-effectiveness analysis (CEA) is based on a multicentre randomised controlled trial encompassing 3,697 patients with hip replacement and 3,110 patients with knee replacement enrolled from 2019 to 2020 in 9 German hospitals. The analysis was conducted with a subset of 546 hip and 492 knee replacement cases with longitudinal cost data from 24 statutory health insurances. Patients were randomised 1:1 to a PROM-based remote monitoring and alert intervention or to a standard care group. All patients were assessed at 12-months post-surgery via digitally collected PROMs. Patients within the intervention group were additionally assessed at 1-, 3-, and 6-months post-surgery to be contacted in case of critical recovery paths. For the effect evaluation, a PROM-based composite measure (PRO-CM) was developed, combining changes across various PROMs in a single index ranging from 0 to 100. The PRO-CM included 6 PROMs focused on quality of life and various aspects of physical and mental health. The primary outcome was the incremental cost-effectiveness ratio (ICER). The intervention group showed incremental outcomes of 2.54 units PRO-CM (95% confidence interval (CI) [0.93, 4.14]; p = 0.002) for patients with hip and 0.87 (95% CI [-0.94, 2.67]; p = 0.347) for patients with knee replacement. Within the 12-months post-surgery period the intervention group had less costs of 376.43€ (95% CI [-639.74, -113.12]; p = 0.005) in patients with hip, and 375.50€ (95% CI [-767.40, 16.39]; p = 0.060) in patients with knee replacement, revealing a dominant ICER for both procedures. However, it remains unclear which step of the multistage intervention contributes most to the positive effect. The intervention significantly improved patient outcomes at lower costs in patients with hip replacements when compared with standard care. Further it showed a nonsignificant cost reduction in knee replacement patients. This reinforces the notion that PROMs can be utilised as a cost-effective instrument for remote monitoring in standard care settings. Registration: German Register for Clinical Studies (DRKS) under DRKS00019916.

An Overview of Optic Pathway Glioma With Neurofibromatosis Type 1: Pathogenesis, Risk Factors, and Therapeutic Strategies.

Optic pathway gliomas (OPGs) are most predominant pilocytic astrocytomas, which are typically diagnosed within the first decade of life. The majority of affected children with OPGs also present with neurofibromatosis type 1 (NF1), the most common tumor predisposition syndrome. OPGs in individuals with NF1 primarily affect the optic pathway and lead to visual disturbance. However, it is challenging to assess risk in asymptomatic patients without valid biomarkers. On the other hand, for symptomatic patients, there is still no effective treatment to prevent or recover vision loss. Therefore, this review summarizes current knowledge regarding the pathogenesis of NF1-associated OPGs (NF1-OPGs) from preclinical studies to seek potential prognostic markers and therapeutic targets. First, the loss of the NF1 gene activates 3 distinct Ras effector pathways, including the PI3K/AKT/mTOR pathway, the MEK/ERK pathway, and the cAMP pathway, which mediate glioma tumorigenesis. Meanwhile, non-neoplastic cells from the tumor microenvironment (microglia, T cells, neurons, etc.) also contribute to gliomagenesis via various soluble factors. Subsequently, we investigated potential genetic risk factors, molecularly targeted therapies, and neuroprotective strategies for tumor prevention and vision recovery. Last, potential directions and promising preclinical models of NF1-OPGs are presented for further research. On the whole, NF1-OPGs develop as a result of the interaction between glioma cells and the tumor microenvironment. Developing effective treatments require a better understanding of tumor molecular characteristics, as well as multistage interventions targeting both neoplastic cells and non-neoplastic cells.

Anterior approach in the surgical management of multiple lumbar fractures (clinical case)

Lumbar fractures are an urgent medical problem. They are often feature the compression of dural sac and roots followed by neurological deficit. This case study presents the anterior approach surgery as the method of choice for the management of multiple fractures with damage to the A and В columns ensuring optimal decompression of the spinal canal and deformity correction and avoiding multi-stage interventions.

Improving leadership skills of infection prevention and control teams by psychological empowerment: study protocol for a cluster randomised controlled trial (IP-POWER)

IntroductionInfection prevention and control (IPC) teams are routinely confronted with intense emotions in their daily work, as they are involved in many change processes with front-line medical staff, for example,...

Reconstructive surgery in the treatment of congenital pseudarthrosis of the tibia in children using microsurgical techniques: Reconstruction or amputation?

BACKGROUND: Numerous methods are available for the treatment of congenital pseudarthrosis of the tibia, but none of them offers a 100% satisfactory result and does not exclude the development of repeated refractories. One of the treatment methods is vascularized transplantation of a fragment of the fibula into the position of the defect of the tibia. However, the achievement of consolidation of the bone fragments of the lower leg does not stop the series of interventions necessary to restore the function of the affected segment. Therefore, specialists were asked about the advisability of performing amputations as an alternative to long-term and multistage interventions.
 AIM: To analyze the results of the use of microsurgical techniques for the treatment of patients with congenital pseudarthrosis of the tibia and, using the example of a patient, to show the way of multistage reconstruction of the lower limb.
 MATERIALS AND METHODS: The results of the use of microsurgical techniques in the elimination of a defect in the bones of the leg in five patients with congenital pseudarthrosis of the tibia were analyzed. Age, sex, presence of type 1 neurofibromatosis, bone defect size, autograft size, duration of consolidation, osteosynthesis index, refractory, range of joint motion, and secondary deformities of the segments after consolidation were assessed. The course of the patient when performing severe reconstructive interventions to restore the weight-bearing capacity of the limb was described. Vascularized autograft transplantation was performed by a qualified microsurgical team.
 RESULTS: The mean age was 7.8 2.2 years. Boys predominated, and type 1 neurofibromatosis was detected in 60% of the cases. The average defect size was 8.8 1.6 cm, and the autograft size was 10.8 1.6 cm. The duration of fixation was 260 90 days, and the fixation index was 24.6 10.6 days/cm. In two cases, 1 year after the fibula transfer, refractories were noted at the bonegraft interface. In 100% of the cases, patients had fibrous ankylosis at the level of the ankle joint, with a loss of functional range of motion, and in 40% of cases, there were flexionextension contractures of the knee joints with an extension deficit of up to 20. For this observation period, 3 of 5 patients underwent additional surgical interventions to correct the deformities of the affected limb.
 CONCLUSIONS: The use of VFT in patients with congenital pseudarthrosis of the tibia allows restoring the integrity of the tibia. Multiple interventions performed on the same segment can lead to irreversible secondary changes in adjacent joints and loss of function of this limb.

Exploring the strategies for upgrading the rural unqualified health practitioners in West Bengal, India: A knowledge, attitude and practices assessment-based approach

IntroductionRural Unqualified Health Practitioners (RUHPs) are more common in the village health system in India and other developing countries. They only provides primary care to patients with diarrhea, cough, malaria, dengue, ARI/pneumonia, skin diseases, etc. As they are unqualified so their quality of health practices is substandard and inappropriate to practices. Objective and contributionThe intention of this work was to assess the Knowledge, Attitude, and Practices (KAP) of diseases among RUHPs and proposing a blueprint of potential intervention strategies for improving their knowledge and practice. Materials and methodsThe study has used a cross-sectional primary data and adopted quantitative approach. For assessment purpose, a composite KAP Score was constructed for two diseases (malaria and dengue). ResultsThe study observed that the KAP Score amongst the RUHPs are on average (about 50%) in most of the individual variables and composite scores for malaria and dengue in West Bengal, India. Their KAP score increased with age, level of education, working experiences, type of practitioners, using android mobile, work satisfaction, organization membership, attending RMP/Government workshop, heard WHO/IMC treatment protocol. ConclusionThe study suggested multistage interventions includes targeting young practitioners, allopathic and homeopathic quack, launching ubiquitous app-based medical-learning, and government-sponsored workshop should be significant interventions to improve the level of knowledge, change positive attitudes, and adhere to standard health practice.

INSPIRA: study protocol for a randomized-controlled trial about the effect of spirometry-assisted preoperative inspiratory muscle training on postoperative complications in abdominal surgery

BackgroundRehabilitation strategies after abdominal surgery enhance recovery and improve outcome. A cornerstone of rehabilitation is respiratory physiotherapy with inspiratory muscle training to enhance pulmonary function.Pre-habilitation is the process of enhancing functional capacity before surgery in order to compensate for the stress of surgery and postoperative recovery. There is growing interest in deploying pre-habilitation interventions prior to surgery.The aim of this study is to assess the impact of preoperative inspiratory muscle training on postoperative overall morbidity. The question is, whether inspiratory muscle training prior to elective abdominal surgery reduces the number of postoperative complications and their severity grade.MethodsWe describe a prospective randomized-controlled single-centre trial in a tertiary referral centre. The primary outcome is the Comprehensive Complication Index (CCI) at 90 days after surgery. The CCI expresses morbidity on a continuous numeric scale from 0 (no complication) to 100 (death) by weighing all postoperative complications according to the Clavien-Dindo classification for their respective severity.In the intervention group, patients will be instructed by physiotherapists to perform inspiratory muscle training containing of 30 breaths twice a day for at least 2 weeks before surgery using Power®Breathe KHP2. Depending on the surgical schedule, training can be extended up to 6 weeks. In the control group, no preoperative inspiratory muscle training will be performed. After the operation, both groups receive the same physiotherapeutic support.DiscussionExisting data about preoperative inspiratory muscle training on postoperative complications are ambiguous and study protocols are often lacking a clear design and a clearly defined endpoint. Most studies consist of multi-stage concepts, comprehensively supervised and long-term interventions, whose implementation in clinical practice is hardly possible. There is a clear need for randomized-controlled studies with a simple protocol that can be easily transferred into clinical practice. This study examines the effortless adjustment of the common respiratory physiotherapy from currently postoperative to preoperative. The external measurement by the device eliminates the diary listing of patients’ performances and allows the exercise adherence and thus the effect to be objectively recorded.Trial registrationClinicalTrials.govNCT04558151. Registered on September 15, 2020.

Engineered Exosomes with Independent Module/Cascading Function for Therapy of Parkinson's Disease by Multistep Targeting and Multistage Intervention Method.

Current exosome engineering methods usually lead to the damage of exosome morphology and membrane, which cannot meet the complex needs of disease treatment. Herein, the concept of an "independent module/cascading function" is proposed to construct an engineered exosome nanotherapy platform including an independent artificial module and a natural module. The artificial module with movement/chemotaxis function is first synthesized, and then it is controllably combined with the natural exosome module with "one by one" mode through a "differentiated" modification method. The whole process can not only maintain the activity of the natural exosome module, but also endows it with motion ability, so as to realize the purpose of "cascading function" in the process of disease treatment. The above engineered exosomes are used in the treatment of Parkinson's disease (PD). Moreover, the multistep targeting strategy of "disease microenvironment-damaged cells-diseased mitochondria" and the multistage intervention concept of "inhibiting deterioration and promoting repair" are proposed, so as to break through the bottleneck of the existing treatment of PD.

A multi-stage intervention assessing, advising and customising sports bras for elite female British athletes

ABSTRACT Appropriate breast support is recommended in sport; however, what constitutes appropriate support is complex, individual and often sports specific, particularly in elite sport given the wear duration. This intervention educated, assessed and advised elite British female athletes on breasts and bras; those with unresolved issues engaged in bespoke bra interventions. Following educational workshops (n = 80), breast/bra surveys (n = 60), individual bra assessments (n = 37); a rower, shooter, and hockey player participated in the bespoke bra intervention. Eighty-three per cent of athletes rated their breast/bra knowledge as ≤average. Fifty-one per cent experienced breast pain, affecting performance for 29%; seven used medication and one surgery to relieve symptoms. In individual bra assessments most wore ill-fitting, unsupportive bras and wanted bra advice. Bespoke bra interventions eliminated breast pain: for the rower, improved breast position and spine rotation; for the shooter, repositioned tissue and improved performance; and for the hockey player, accommodated smart devices. Whilst bespoke bra development is challenging, most elite athlete breast/bra issues are resolved via education, advice and fitting.

256 Implementing and Reinforcing Positive Change to Regional Hand Trauma Service with Introduction of the Golden Patient Initiative

Abstract Introduction Significant theatre delays were identified in hand trauma lists at our regional adult hand surgery unity. We aimed to improve theatre delays by implementing a golden patient initiative. Method Literature review identified the golden patient initiative, which ensures first patient on the list is identified, communicated to multidisciplinary team, and is optimized for theatre. Multi-stage intervention according to change management models (ADKAR and McKinsey 7s) was used. This included (1) a new protocol, (2) educational intervention, 3) poster and (4) a variety of information dissemination methods. To ensure multidisciplinary staff engagement and reinforce positive change, we used multiple verbal, visual and written prompts: trauma co-ordinator-led daily reminders, senior involvement, new column in handover list, verbal reminders at departmental meetings, posters in key areas and widely-accessible reference booklet. Prospective analysis of theatre utilisation pre- and post-intervention to measure impact of intervention. Results Analysis of emergency general list (EG) and local anaesthetic list (LA) start times identified an average 40 and 20-minute-long delays respectively. Following introduction of golden patient there was a reduction in delays by 9 minutes in LA and 5 minutes in EG. The latest start time improvement by 8 minutes in LA and 50 minutes in EG. There was also a reduction in operation delays by 2.8% in LA and 14.3% in EG. The estimated annual cost saved in EG is approximately £45,200. Conclusions We believe that implementing sustainable change is a complex and challenging process. Implementing the golden patient initiative resulted in a positive impact on hand trauma services.

Abstract 10298: Improving the Ability to Assess and Detect Delirium in Postoperative Cardiac Surgery Patients

Introduction: Delirium is common in cardiac intensive care units due to illness related stress, polypharmacy, interventions, excessive light and noise, disorientation and sleep disruption. Delirium assessment is poor due to limited nursing knowledge and the lack of integrated features in electronic health platforms (EHR) to support accurate assessment and documentation. Hypothesis: We hypothesized that education on use of the Confusion Assessment Method for the ICU (CAM-ICU) and enhanced features in the EHR would improve the ability to detect delirium in our CTICU. Methods: We conducted a QI intervention using a PDSA approach and pre-post evaluation design. In the Planning phase audited 100 randomly selected charts to determine baseline documentation of delirium. We conducted a survey of nurses’ knowledge of delirium and documentation criteria and identified a knowledge deficit. In the Do phase, a multi-stage educational initiative was used to address delirium awareness, knowledge, and CAM-ICU documentation competency. Enhancements in the EHR were made to enable accurate assessment, documentation and scoring using embedded logic. Post-intervention audits (n=100) were performed. Results: Survey respondents (n=64) averaged 31 years old (SD 1.4) and had 6 years nursing experience on average (median=3, range <1-40). Nurses believed patients with delirium had longer ICU LOS and worse outcomes and patients would benefit from screening. Most lacked training in delirium screening (88.1%, n=58). Baseline documentation of at least one assessment of delirium was 44% (n=44) and post-intervention was 100% (p<0.001). Accuracy of CAM-ICU assessments at baseline was challenging to determine due to a single field (YES/NO/UTA) in the EHR, however, positivity of pre-intervention assessments was 1% (n=1) and post- intervention at least 1 positive CAM score was recorded in 33% (n=33) of patients (p<0.001). Conclusions: Findings suggest that a multi-stage educational intervention paired with EHR integrated scoring logic improves awareness, knowledge and documentation accuracy for delirium in the ICU, which may improve patient safety and ICU outcomes. Better assessment and documentation may improve patient safety and ICU outcomes.

A new smoking cessation 'cascade' among women with or at risk for HIV infection.

The aim of this study was to define a smoking cessation 'cascade' among USA women with and without HIV and examine differences by sociodemographic characteristics. An observational cohort study using data from smokers participating in the Women's Interagency HIV Study between 2014 and 2019. We followed 1165 women smokers with and without HIV from their first study visit in 2014 or 2015 until an attempt to quit smoking within approximately 3 years of follow-up, initial cessation (i.e. no restarting smoking within approximately 6 months of a quit attempt), and sustained cessation (i.e. no restarting smoking within approximately 12 months of a quit attempt). Using the Aalen-Johansen estimator, we estimated the cumulative probability of achieving each step, accounting for the competing risk of death. Forty-five percent of smokers attempted to quit, 27% achieved initial cessation, and 14% achieved sustained cessation with no differences by HIV status. Women with some post-high school education were more likely to achieve each step than those with less education. Outcomes did not differ by race. Thirty-six percent [95% confidence interval (95% CI): 31-42] of uninsured women attempted to quit compared with 47% (95% CI: 44-50) with Medicaid and 49% (95% CI: 41-59) with private insurance. To decrease smoking among USA women with and without HIV, targeted, multistage interventions, and increased insurance coverage are needed to address shortfalls along this cascade.

Esophagoplasty with a Combined Visceral Graft

The problem of unsuccessful (incomplete) esophagoplasty is still urgent nowadays. Simultaneous esophagoplasty remains a method of choice in reconstructive surgery of the esophagus. However, in the case of ischemic disorders in the transplant, its initially insufficient length, deficiency of the organs of the plastic reserve, the completion of esophagoplasty seems to be a technically complicated task, forcing surgeons to perform multi-stage intervention techniques. These techniques are associated with longer treatment periods and deterioration in the quality of life of patients.The article highlights a rare experience of esophagoplasty with combined grafts consisting of visceral segments on a natural source of blood circulation. Applied operational techniques allowed to complete esophagoplasty in a single step, including rational disposal of compromised plastic material, and also to preserve digestion.

Knowledge and attitudes of Spanish mental health professionals towards advance healthcare directives.

WHAT IS KNOWN ON THE SUBJECT?: AHDs in mental health are fundamental tools in advance care planning processes. It is an important method for involving mental healthcare users in clinical decisions and in providing effective healthcare based around user preferences. AHDs can be applied in situations in which the person may forfeit their legal capacity, according to the Convention on the Rights of Persons with Disabilities. However, the use of AHDs as described above is not yet a reality in Spain. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The present study surveys the knowledge and attitudes of mental healthcare providers towards AHDs in clinical practice. Although providers had a moderate-low level of knowledge about AHDs, they presented positive attitudes towards them. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The use of AHDs in mental healthcare practice poses challenges to the Spanish mental healthcare system. Acquiring up-to-date data on the knowledge and attitudes of providers towards AHDs allows organizations to address aspects of their service that require reinforcement. This data could also be used by other countries just starting to use AHDs, as an initial step towards supporting the implementation of a multistage intervention process. More in-depth training for providers would help improve their competence to implement or honour the statements set out in AHDs, the related legal and ethical issues, and liability issues related to their implementation. The Spanish mental healthcare system requires structural changes so that providers can embrace new ways of relating to users and to organize partnerships and a continuity of care centred on user preferences. ABSTRACT: Introduction Advance healthcare directives (AHDs) in mental health offer important information regarding service users' preferences. However, whether AHDs are truly understood by providers is questionable. Aim To survey the knowledge and attitudes of mental health professionals towards AHDs and examine any associations with sociodemographic and occupational variables. Method We cross-sectionally surveyed the knowledge and attitudes of 113 mental health professionals by using two validated questionnaires. Results Participants showed very positive attitudes and high levels of knowledge about the conceptual definition and application of AHDs in clinical practice but their knowledge of the legalities, procedure and registration of AHDs was poor. Working in a community, having a career specializing in mental health or having personally signed an AHD was associated with enhanced knowledge about them. Moreover, female sex or employment as an auxiliary nursing-care technician was associated with stronger positive attitudes. Discussion Legal and structural changes will be needed to implement AHDs in Spain and to promote competence among healthcare providers in order to include AHDs in everyday practice. Implications for practice The Spanish mental healthcare system requires legal and structural changes and must improve healthcare providers' competence in AHDs before they are implemented.

Intervention fidelity in postintensive care follow-up consultations at ten sites in the RAPIT-trial: A mixed-methods evaluation.

The aim of the study was to evaluate intervention fidelity of nurses' delivery of the RAPIT recovery program for postintensive care patients. Interventions addressing patient problems after intensive care lack description of the process of delivery and the evidence of their effectiveness. This is needed to understand how these interventions work. Multistage intervention framework in a mixed-methods design. Intervention fidelity strategies were assessed for intervention design, training, delivery, receipt, and enactment with quantitative and qualitative methods inspired by the Medical Research Council and the National Institutes of Health Fidelity Framework. Data collection was embedded in a multicenter randomized controlled trial to explore intervention fidelity of a recovery program (December 2012-February 2017). Ten Danish intensive care units participated in the RAPIT-trial including 386 patients and 27 nurses. Quantitative data covered training and delivery. Qualitative data explored design, quality of delivery, receipt, and enactment seen from nurses' and patients' perspectives. Data were analysed statistically and by systematic deductive-inductive thematic analysis. A framework for participatory enactment of a complex intervention was developed and demonstrated delivery with high consistent fidelity across sites. Low delivery doses and variations were related to the program, patient, provider nurses and context. Our study provides insight into the process of intervention fidelity of a nurse-led postintensive care recovery program and potentially enables professionals to understand key factors in cross-site implementation. Although we demonstrate consistent delivery and variations suggest that some patients may benefit more than others.

Surgical treatment of a patient with posttraumatic syringomyelia associated with complex posttraumatic deformity of the spine

A clinical case of surgical treatment of a female patient with posttraumatic syringomyelia which led to tetraparesis and dissociated sensory loss in the trunk and upper and lower limbs is presented. Clinical manifestations of these spinal cord changes occurred 21 years after complicated fracture of the L1 vertebra associated with complex posttraumatic spinal deformity. Multistage surgical intervention made it possible to restore liquorodynamics, perform the necessary correction of severe kyphotic deformity of the spine, and reduce the risk of torso imbalance. As a result, the syrinx practically disappeared at all levels of the study.

Evaluation of hydraulic controls for leakage intervention in carbon storage reservoirs

Assuring the storage security of geologically sequestered CO2 is essential for proper project management and long-term emissions reductions. Storage security relies not only on comprehensive site characterization prior to injection and careful reservoir management, but also on having a suite of intervention and remediation strategies available to implement if leakage occurs. In this study sequential stages of intervention are analyzed and evaluated. The first step in halting leakage is likely to be stopping CO2 injection in the vicinity of the leak (also termed passive remediation). Results indicate that while passive remediation can reduce the leakage rate by an order of magnitude, completely stopping leakage may often require implementation of additional measures. Additional measures evaluated here focus largely on hydraulic controls, whereby water is injected or produced in or above the CO2 injection reservoir in order to terminate leakage. The degree of residual trapping determines the extent to which leakage is ultimately reduced. For example, water injection into the overlying aquifer directly above a fault was able to completely terminate leakage for as long as water injection continues. Remediation was even more effective when water injection above the fault was combined with reservoir fluid production. We also show that in addition to hydraulic control methods, extracting 15–25% of the injected CO2 can lead to permanent leakage termination. The role of reservoir heterogeneity on remediation efficacy was also examined and found to reduce the total amount of CO2 leaked compared to a homogeneous reservoir. Overall this study demonstrates that temporally limited, multi-stage intervention strategies such as hydraulic barriers can permanently stop CO2 leakage from storage reservoirs into overlying aquifers.

THE MODERN CONCEPT OF EARLY DETECTION AND TREATMENT OF IDIOPATHIC SCOLIOSIS

RETRACTED The paper presents the tactics of early detection and treatment of idiopathic scoliosis adopted in Novosibirsk NIITO. Idiopathic scoliosis is a genetically determined disease. Its early detection requires screening of children and adolescents. The most effective conservative method is brace treatment. Surgical treatment is strictly differentiated depending on the age of a patient. Patients in the first decade of life are treated by multi-stage surgery with VEPTR instrumentation. Patients aged 11-13 years undergo one-step intervention using transpedicular fixation of the whole curve. Patients aged 14-20 years are treated in one- or two-stage intervention depending on the curve mobility. Deformities over 90° require multi-stage intervention with anterior and posterior mobilization of the spine.

A quality improvement project to decrease emergency department and medical intensive care unit transfer times

ObjectiveTo reduce transfer time of critically ill patients from the emergency department (ED) to the medical intensive care unit (MICU). DesignA prospective, observational study assessing preimplementation and postimplementation of quality improvement interventions in a tertiary academic medical center. InterventionsA team of frontline health care professional including ED, MICU, and supporting services using the clinical microsystems approach mapped out existing practice patterns, determined causes for delays, and used the Plan-Do-Study-Act to test changes.Measurements and Main ResultsThe team identified multiple issues that contributed to delays. These included poor coordination between transport services, respiratory therapy, and nursing in transferring patients from the ED as well delays in identification and transfer of stable MICU patients. These interventions reduced transfer time from 4.2 (3.4-5.7) hours to 2.2 (1.4-3.1) hours (median [interquartile range]; P < .001). Hospital length of stay decreased from 9.9 ± 9 to 8.3 ± 7 days (P < .03). ConclusionA team made up of frontline health care professionals using a structured quality improvement process and implementing multifaceted, multistage interventions, reduced transfer delays, and length of stay. Added benefits included engagement among members of the 2 microsystems and a more cohesive approach to patient care.

Colorectal cancer complicated by perforation. Specific features of surgical tactics

Objective: to assess the immediate results of surgical interventions for colorectal cancer complicated by perforation. Materials and methods. The immediate results of surgical treatment were retrospectively analyzed in 56 patients with colorectal cancer complicated by perforated colon cancer, who had been treated at Smolensk surgical hospitals in 2001 to 2013. Patients with diastatic perforation of the colon in the presence of decompensated obturation intestinal obstruction of tumor genesis were not included into this investigation. Results. The immediate results of uni- and multistage surgical interventions were analyzed in relation to the extent of peritonitis and the stage of colon cancer. More satisfactory immediate results were observed after multistage surgical treatment. Following these interventions, a fatal outcome of disseminated peritonitis in the presence of performed colorectal cancer was recorded in 8 (53.3 %) cases whereas after symptomatic surgery there were 11 (67.8 %) deaths. A fatal outcome was noted in 1 case (7.7 %) after multistage surgery. Discussion. The results of surgical treatment in the patients with perforated colorectal cancer are directly related to the degree of peritonitis and the choice of surgical tactics.