Regular Multidisciplinary Meetings Research Articles

The long-term impact of an antimicrobial stewardship program in febrile neutropenia: an 8 years follow up.

To describe the long-term effects of an ASP among febrile neutropenia (FN) patients. A quasi-experimental study was conducted between 2015 and 2023 at a tertiary care hospital in Istanbul, Türkiye. The ASP was implemented for FN patients, and the effects were assessed before and after the ASP interventions, which included FN clinical pathways and regular multi-disciplinary meetings with relevant healthcare workers. A total of 489 FN episodes of 290 patients were included, 42% were female, and the mean age was 56 years (SD: 15, range: 18-89 years). After the intervention, the rate of appropriate antimicrobial therapy at the levels of starting (p = 0.005), switching (p < 0.001), and de-escalation/discontinuation, (p < 0.001) significantly increased. Another positive impact of the ASP was a significant reduction in candidemia (from 4.88 to 0.74, p = 0.004), as well as a significant reduction in the 90-day mortality rate (from 19 to 5%, p < 0.001). In multivariate analysis, having a gram-negative bloodstream infection, prolonged days with fever, and a high risk for neutropenia were found to be significant predictors of 90-day mortality, while follow-up with ASP significantly reduced mortality. Implementation of ASP led to reduced candidemia and LOS without increasing mortality, even in a country with a high rate of antimicrobial resistance. Implementation of sustainable ASP for FN patients is critical in combating antimicrobial resistance.

Collaborating with non-radiological clinical colleagues.

Paediatric radiology is a challenging and intriguing subspecialty, dealing with children, guardians and non-radiological clinical colleagues. Paediatric radiologists are routinely in contact with numerous paediatric and surgical subspecialties, all having different needs, perceptions, prioritisations and expectations. Moreover, the radiologist is part of the team of radiographers, sonographers, nurses and secretaries, assisted by appropriate equipment and electronic tools. The framework of good collaboration to ensure safety and effectiveness for the imaged child is a shared responsibility among all medical practitioners involved. Communication in routine practice has many forms and includes appropriately filled radiology requests in accordance to the patient's medical records, routine and timely production of structured, problem-solving radiology reports, face-to-face or electronic-assisted communications and discussions on a pre-defined framework, mutually-agreed and evidence-based protocols adjusted to local availability, skills and national and international guidelines. Mutual understanding of advantages and limitations of imaging is paramount. Well-meant discussions, professionalism and empathy should promote soft skills, bidirectional communication and good collaboration for the benefit of added-value paediatric radiology. International societies, health authorities, medical directors and senior consultants have the responsibility to suggest and safeguard frameworks and recommendations. Regular multidisciplinary meetings and multidisciplinary research projects under openness, honesty and transparency are pathways favouring good collaboration.

Multidisciplinary approach to patients with lymphatic conduction disorders

Patients with lymphatic disorders are remarkably complex and require a wide variety of medical and surgical services. Establishing a multidisciplinary program improves the efficiency of the patients’ hospital experience minimizing the compartmentalization of their care. Offering a clear intake process guarantees that patients will be seen promptly by all the required teams. Additionally, having regular multidisciplinary meetings allows all participating teams to learn from each other and gain experience in the care of a population that is extraordinarily heterogeneous. Additionally, establishing a solid program allows for long-term data collection, research and education.

Successful complete oral rehabilitation of a patient with osteopetrosis with extensive pre-treatments, bone grafts, dental implants and fixed bridges: a multidisciplinary case report

BackgroundOsteopetrosis comprises a group of inherited disorders that are rare and result in abnormal bone structure. Bone remodeling is extremely inhibited because osteoclasts are nonfunctional or lacking. This condition causes overgrowth of bone with disappearance of the bone marrow, leading to aplastic anemia; obstruction of nerve passages in the skull leads to blindness and often hearing impairment. In most cases, osteopetrosis results in oral complications such as tooth deformation, hypomineralization, and delayed or absent tooth eruption. The only curative treatment is hematopoietic stem cell transplantation (HSCT). The main treatment of the oral complications during childhood and adolescence consists in protecting the erupted teeth against caries disease through prophylactic treatment aimed at optimal oral hygiene through frequent regular dental visits throughout life. Many patients with osteopetrosis require major oral rehabilitation to treat complications of the disease. Improved results of HSCT increase the likelihood that dental professionals will encounter patients with osteopetrosis.Case presentationIn this case report, we show that individuals with osteopetrosis who have severe oral complications can be treated successfully if they are treated for osteopetrosis at an early age. The boy had his dental care in pedodontics, and regular multidisciplinary meetings were held for future treatment planning. At the age of 15, he was then referred for rehabilitation. The initial evaluations revealed no further growth in the alveolar bone. The rehabilitation was done stepwise, with extraction of malformed and malpositioned teeth. Initially, the patient received a removable partial denture followed by reconstruction of the width of the alveolar process, titanium implants, temporary fixed bridges, and finally screw-retained titanium–ceramic bridges with titanium frames for the upper and lower jaws.ConclusionsThe three-year follow-up after loading indicated a stable marginal bone level and optimal oral hygiene as a result of frequent professional oral hygiene care. The patient showed no signs of symptoms from the temporomandibular joint and has adapted to the new jaw relation without any functional or phonetical issues.

OTHR-08. MULTIDISCIPLINARY APPROACH TO PAEDIATRIC BRAIN CANCER BIO-BANKING IMPROVES ENROLLMENT, FACILITATES DISCOVERY RESEARCH, AND ENABLES BETTER ACCESS TO DIAGNOSTIC AND THERAPEUTIC STUDIES

Abstract Despite the significant progress made in the multi-modal treatment of childhood malignancies over the last four decades with a concomitantly increased cure rates, the benefit is still largely limited to patients with leukemias, lymphomas and localized non-CNS solid tumors, leaving patients with high-risk non-CNS solid tumours and most CNS malignancies with minimal advancements. More research is critical to understand what drives these cancers and to investigate the best ways to deliver curative therapies. Translational research relies on patient-derived tissue samples, animal models and cell-cultures to understand the biological, genetic, and molecular mechanisms of disease. To facilitate patient care and outcomes it is becoming increasingly important that paediatric clinical trials include tissue availability as part of eligibility criteria, making collection and storage of patient tissue a mandate of personalized medicine and a pillar of modern paediatric cancer medicine. Monash Children’s Cancer Biobank was established in 2011. Since 2017, a total of 64 patients were diagnosed with CNS malignancies across all grades, with an overall 69% of patients’ tissues being bio-banked at the time of initial diagnosis. Through the combination of an educational forum, regular multi-disciplinary meetings, and the early involvement of medical oncology and biobank staff, with our neurosurgical and clinical pathology colleagues, as part of patient management planning, the tissue acquisition for bio-banking increased from 44% to 82% over the course of 5 years. This consequently led to a 100% enrollment to tissue-enabling studies allowing for banking of both fresh-frozen tissue and living cell-line models, facilitating discovery research efforts as part of the Victorian Paediatric Cancer Consortium’s molecular analysis pipeline (https://vicpcc.org.au/dashboard). This significantly improves opportunities for identification of targetable pathways, access to targeted therapies, enrollment onto treatment clinical trials and identification of patients with cancer predisposition syndromes.

Cardiotocography in practice: a qualitative study to explore obstetrical care professionals’ experiences with using cardiotocography information in Dutch practice

ObjectiveThis study aimed to explore obstetric care professionals’ experiences with using cardiotocograph (CTG) information and how they employ this tool in their practice.DesignQualitative study, involving 30 semi-structured interviews and two...

EPCT-08. Disease-specific working groups within the Pacific Pediatric Neuro-Oncology Consortium (PNOC) and Children’s Brain Tumor Network (CBTN) facilitate multi-disciplinary collaboration and translation of innovative strategies in pediatric neuro-oncology

Abstract BACKGROUND: In Summer 2019, PNOC leadership developed working groups to align basic scientists, clinical researchers, and foundations for rapid translation of novel therapies for children and young adults with central nervous system tumors. Soon after, PNOC partnered with the Children’s Brain Tumor Network (CBTN) to grow collaborations and augment preclinical resources. Since their inception, working groups have advanced translation of new therapies and biomarkers, developed pipelines for preclinical and clinical research, and expanded global collaborations. DESIGN: Each working group is led by 2 to 3 experts in a disease, such as medulloblastoma, diffuse midline glioma, or craniopharyngioma, or subject matter, like imaging, nursing, or diversity, equity, and inclusion. A project manager coordinates regular multidisciplinary meetings to share new findings from research laboratories, provide updates on clinical trial development (with real-time feedback and incorporation of trial endpoints and biomarkers), and invite speakers to share advancements in the disease or subject of interest. RESULTS: Eleven working groups have been created with over 200 members across the United States, Europe, Australia. More than 20 foundations, led predominantly by families, provide support and insight to guide working group efforts. Working groups have developed 4 clinical trials (n=2, diffuse midline glioma; n=1, craniopharyngioma; n=1, medulloblastoma) and completed 3 international surveys, investigating experiences of patients/families affected by craniopharyngioma, evaluating diversity and inclusion throughout the consortia, and assessing nursing and advanced practice provider needs. Additional accomplishments include a registry for atypical teratoid rhabdoid tumors, a population dataset evaluating diversity in clinical research participation across consortia, incorporation of nursing members for review and refinement of clinical trial protocols, and updated imaging case report forms for application across clinical trials. CONCLUSION: Multidisciplinary working groups within international consortia facilitate efficient translation of multi-pronged strategies to improve the care of children and young adults with central nervous system tumors.

Leveraging financial incentives and behavioural economics to engage physicians in achieving quality-improvement process measures.

Background:Dedicated quality-improvement (QI) initiatives within health care systems are of clear benefit, and physicians respond to financial incentivization. The Canadian health care system often lacks this lever, and many financially incentivized QI programs rely on traditional economic principles. We describe our evaluation of financial incentivization for the implementation of QI process metrics in a department of surgery at a Canadian academic hospital system and its impact over a 4-year period.Methods:Quality-improvement processes informed by extant QI incentivization literature and guided by the principles of behavioural economics were implemented within our institution’s Department of Surgery. Disbursement of supplemental government funding was modified to be contingent on the ability of divisions within the department to meet predefined QI metrics, including regular multidisciplinary meetings, morbidity and mortality rounds with documented feedback of systemic issues to division members, reviews of adverse events, and implementation of annual patient experience projects. We evaluated the effect of the QI processes from 2015/16 to 2018/19.Results:There was a significant increase in the number of divisions that satisfied all the QI metrics over the study period, from 2 (28%) in 2015/16, to 5 (71%) in 2016/17, to 7 (100.0%) in 2017/18 and 2018/19 (p < 0.01). The application of behavioural economics principles, such as reward versus penalty payoff, loss aversion, payment separation, aligning of values, and relative social ranking, was important to the outcome of the study.Conclusion:Incentivizing QI activities in the Canadian health care system is possible and led to improvement in QI processes as a whole in our department. This paper lays out a method of financial reimbursement to facilitate engagement of physicians and establishment of a foundation of important QI processes and measures within a department.

Learning mechanisms and outcomes of an interprofessional molecular pathology workshop for residents

The developments in targeted therapies and molecular pathology have changed the classification of tumors and precision oncology. Pathologists and clinical scientists in molecular pathology and oncologists have regular multidisciplinary meetings and are responsible for translating molecular results into an appropriate treatment plan. This requires expertise and skills to be effective team players. Interprofessional collaboration (IPC) is essential for professionals in medicine; however, learning opportunities in current resident training are limited. This narrative study explores the collaborative output and learning mechanisms of interprofessional learning (IPL) of residents of different disciplines in the Morphology & MolecularPLUS workshop and its preparation. Topics that were discussed in the workshop were technologies for the detection of mutations, copy number variations, tumor mutational burden, and circulating tumor DNA (ctDNA) analysis in the context of differential diagnosis and precision oncology. Data were collected by analyzing pre- and post-workshop questionnaires and interviews. An interprofessional team of three residents of each hospital had to be formed by one of the residents, which was challenging as not all residents from a hospital knew each other. Residents reported to have got to know each other and have learned about each other's roles and perspectives. They gained knowledge of molecular pathology and the added value of IPC, in particular, for residents early in their training. Enabling meetings for medical residents of different disciplines to get acquainted was perceived as the most facilitating factor for IPL. Time constraints as the biggest barrier in daily practice. We recommend offering IPL activities as early as possible in residency programs.

Institutional factors associated with adherence to enhanced recovery protocols for colorectal surgery: Secondary analysis of a multicenter study

IntroductionAdherence to Enhanced Recovery Protocols (ERPs) is associated with faster functional recovery, better patient satisfaction, lower complication rates and reduced length of hospital stay. Understanding institutional barriers and facilitators is essential for improving adherence to ERPs. The purpose of this study was to identify institutional factors associated with adherence to an ERP for colorectal surgery. MethodsA secondary analysis of a nationwide study was conducted including 686 patients who underwent colorectal surgery across twenty-one institutions in Spain. Adherence to ERPs was calculated based upon the components recommended by the Enhanced Recovery After Surgery (ERAS®) Society. Institutional characteristics (i.e., case volume, ERP duration, anesthesia staff size, multidisciplinary meetings, leadership discipline) were captured from each participating program. Multivariable regression was performed to determine characteristics associated with adherence. ResultsThe median adherence to ERAS was 68.2% (IQR 59.1%–81.8%). Multivariable linear regression revealed that anesthesiologist leadership (+5.49%, 95%CI +2.81% to +8.18%, P < 0.01), duration of ERAS implementation (+0.46% per year, 95%CI +0.06% to +0.86%, P < 0.01) and the use of regular multidisciplinary meetings (+4.66%, 95%CI +0.06 to +7.74%, P < 0.01) were independently associated with greater adherence. Case volume (−2.38% per 4 cases weekly, 95%CI -3.03 to −1.74, P < 0.01) and number of anesthesia providers (−1.19% per 10 providers, 95%CI +2.23 to −8.18%, P < 0.01) were negatively associated with adherence. ConclusionAdherence to ERPs is strongly associated with anesthesiology leadership, regular multidisciplinary meetings, and program duration, whereas case volume and the size of the anesthesia staff were potential barriers. These findings highlight the importance of strong leadership, experience and establishing a multidisciplinary team when developing an ERP for colorectal surgery.

Les Consignes Médicales en Psychiatrie, définition législative et état des lieux bibliographiques

IntroductionMedical instructions are a well spread practice among French psychiatric wards, yet they are non homogeneous. There is not even a univocal name to specify it. ObjectivesFrom a descriptive approach of the ordinary practice of medical instructions, we will make an operational definition for them. From there, we will look for its definition and delimitation through legislative, jurisprudence, and deontological corpus, and clarify its difference with a medical prescription. We will extend the bibliography by a medical search through the scientific literature and French guidelines. MethodsA review of the French Code de Santé Publique, the deontological code from the French Medical Order, the reports of the Contrôleur Général des Lieux de Privation de Liberté (the General Controller of Liberty Deprival Places), and the French jurisprudence. We proceeded with keywords. As for the medical bibliography, we looked through the scientific literature as well as in the French guidelines from the Haute Autorité de la Santé. ResultsWe found no legislative caracterisation of medical instructions. When mentioned, they are not considered as medical prescriptions, but rather as a medical practice, or general care strategy, which the doctor is (the only one) responsible for. The jurisprudence clearly delimits the liberty restrictions that are possible for a medical doctor to prescribe, in the context of a suicidal risk. The CGPL reports point at various use of the “care framework” as a reason to limit the freedom of movement, without a proper medical necessity. The guidelines mostly raise the difficulty at stake with this practise (in terms of scientific validation and ethics), rather than suggesting the modality of its use. Medical literature does not provide focused studies on medical instructions. They do reveal their uses, and we have found several paramedical authors addressing them. DiscussionMedical instructions are a difficult object to study with the methodology of Evidence Based Medicine, because they are not quantifiable. Epistemological work could bring us some insight over this very contemporary practise. Alongside of which, case report studies are necessary to underline the different problematics at stake through the various systems they imply: the doctor-patient one, the doctor-staff and the staff-patient ones. Our bibliographic review has revealed how medical instructions are a singular object, from one prescriber (the doctor) but supported by teamwork and moreover permitting its coherence, its effectiveness. ConclusionWe have arrived to an operational definition of medical instructions: they are a medical order, with an individual therapeutic aim, that the staff has to execute, also the patient has a right to refuse it (like all treatment, emergencies aside). Medical instructions are not a law (that could lead to punition), nor an internal regulation (it is not general but individually thought), and neither a simple advice (the staff is bound to execute it). Medical instructions are a practical entry point to study the broader “care framework” that conditions the practice of institutional psychiatric care. We believe a good practise of medical instructions has to be reflected on, through regular Multidisciplinary meetings, inclusive of the different health care professionals involved: so they can be evaluated properly, and benefit from a comprehensive execution.

A review on the impact of lung cancer multidisciplinary care on patient outcomes.

International guidelines recommend a multidisciplinary approach to the management of lung cancer due to the complexity of both patients and their disease and the multiple treatment options available. This care can be provided through patient discussion at multidisciplinary meetings where relevant medical and allied health staff formulate a consensus management plan taking all factors into consideration. This model can be extended further to include multidisciplinary clinics where the patient is present for assessment and discussion. However, conducting regular multidisciplinary meetings or clinics has significant time, resource and financial costs and therefore, it is important to assess the impact of multidisciplinary care. We aimed to review published evidence, from 2000 to 2019, to evaluate the impact of multidisciplinary care on lung cancer outcomes. There were 29 studies found, 11 evaluating multidisciplinary clinics, 14 studying multidisciplinary meetings and four where the model of care was not defined. There was only one randomised trial and three prospective studies, the remainder being retrospective studies. Despite limitations in trial design and confounding factors, overall, multidisciplinary care in lung cancer was associated with improvements in patient outcomes, in particular improved survival for all stages of lung cancer. Lung cancer patients managed in a multidisciplinary setting were more likely to receive active treatment and had improved utilisation of all treatment modalities: surgery, radiotherapy and chemotherapy. In addition, the treatment recommendations were more likely to be consistent with lung cancer management guidelines. These improved outcomes support the recommendations for a multidisciplinary approach to lung cancer care.

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.

Survey of Physician's Knowledge, Attitudes, and Practices Regarding Idiopathic Pulmonary Fibrosis in Turkey.

The aim of this study is to evaluate the approaches of Turkish pulmonologists to the diagnosis and treatment of idiopathic pulmonary fibrosis (IPF) in daily clinical practice. A questionnaire containing 38 questions about the IPF diagnosis and treatment was given to pulmonologists between January 22 and 29, 2018, and the data of 158 physicians who responded to the questionnaire were evaluated. This survey showed that the mean number of patients that physicians followed up and managed annually was 8.3 and 5, respectively. The mean symptom duration before the diagnosis was 9-12 months. Patients were seen on average by three physicians prior to confirmed diagnosis. Almost 80% of the physicians have an opportunity to access a pathologist and radiologist specialized in IPF. However, only 26% of them have an opportunity to access regular multidisciplinary meetings. Although antifibrotics were the most commonly prescribed drugs, approximately 10% of patients were prescribed steroids, N-acetylcysteine, and immunosuppressants. Most of the physicians (81%) were aware of international guidelines; however, the Turkish Thoracic Society IPF Diagnosis and Treatment Consensus Report was read by only 41% of them. This survey may lead to the IPF awareness in Turkey, and it may help to close the gaps regarding the diagnosis and treatment.

Barriers to and Facilitators of End-of-Life Decision Making by Neonatologists and Neonatal Nurses in Neonates: A Qualitative Study

ContextMaking end-of-life decisions (ELDs) in neonates involves ethically difficult and distressing dilemmas for health care providers. Insight into which factors complicate or facilitate this decision-making process could be a necessary first step in formulating recommendations to aid future practice. ObjectivesThis study aimed to identify barriers to and facilitators of the ELD-making process as perceived by neonatologists and nurses. MethodsWe conducted semistructured face-to-face interviews with 15 neonatologists and 15 neonatal nurses, recruited through four neonatal intensive care units in Flanders, Belgium. They were asked what factors had facilitated and complicated previous ELD-making processes. Two researchers independently analyzed the data, using thematic content analysis to extract and summarize barriers and facilitators. ResultsBarriers and facilitators were found at three distinct levels: the case-specific context (e.g., uncertainty of the diagnosis and specific characteristics of the child, parents, and health care providers, which make decision making more difficult), decision-making process (e.g., multidisciplinary consultations and advance care planning, which make decision making easier), and overarching structure (e.g., lack of privacy and complex legislation making decision making more challenging). ConclusionBarriers and facilitators found in this study can lead to recommendations, some simpler to implement than others, to aid the complex ELD-making process. Recommendations include establishing regular multidisciplinary meetings to include all health care providers and reduce unnecessary uncertainty, routinely implementing advance care planning in severely ill neonates to make important decisions beforehand, creating privacy for bad-news conversations with parents, and reviewing the complex legal framework of perinatal ELD making.

Differences in primary palliative care between people with organ failure and people with cancer: An international mortality follow-back study using quality indicators

Background: Measuring the quality of palliative care in a systematic way using quality indicators can illuminate differences between patient groups. Aim: To investigate differences in the quality of palliative care in primary care between people who died of cancer and people who died of organ failure. Design: Mortality follow-back survey among general practitioners in Belgium, the Netherlands, and Spain (2013–2014), and Italy (2013–2015). A standardized registration form was used to construct quality indicators regarding regular pain measurement, acceptance of the approaching end of life, communication about disease-related topics with patient and next-of-kin; repeated multidisciplinary consultations; involvement of specialized palliative care; place of death; and bereavement counseling. Setting/participants: Patients (18+) who died non-suddenly of cancer, cardiovascular disease, or respiratory disease (n = 2360). Results: In all countries, people who died of cancer scored higher on the quality indicators than people who died of organ failure, particularly with regard to pain measurement (between 17 and 35 percentage-point difference in the different countries), the involvement of specialized palliative care (between 20 and 54 percentage points), and regular multidisciplinary meetings (between 12 and 24 percentage points). The differences between the patient groups varied by country, with Belgium showing most group differences (eight out of nine indicators) and Spain the fewest (two out of nine indicators). Conclusion: People who died of organ failure are at risk of receiving lower quality palliative care than people who died of cancer, but the differences vary per country. Initiatives to improve palliative care should have different priorities depending on the healthcare and cultural context.

Patients, physicians and nursing personnel in intensive care units: Psychological and psychotherapeutic interventions

During intensive care treatment patients suffer from various forms of stress. Certain psychological and psychotherapeutic interventions (e. g. cognitive behavior therapy, hypnotherapy and psychoeducation) can provide relief. Even patients with a severely reduced ability to communicate can benefit from an early psychological intervention as supportive treatment. The aim of these interventions is to reduce psychological impairments and burdens, provide strategies for coping with physical handicaps or necessary treatment and avoid long-term negative psychological impacts. Organizational and institutional constraints as well as emotional stress are a specific challenge for intensive care personnel. In order to guarantee an efficient collaboration within an interdisciplinary team it is vital to follow clearly defined methods of communication exchange, such as daily ward rounds, regular multidisciplinary meetings and team or case-focused supervision. Properly functioning teamwork increases job satisfaction and is the key to an optimal therapy for the patients.

Innovative care model for patients with complex muscle diseases.

Many neuromuscular disorders require complex multisystem management. This is especially true for the rapidly growing numbers of young adults surviving congenital and childhood onset conditions following improved multidisciplinary care and the routine use of home ventilation. Surveys from the United Kingdom and Netherlands indicate that neuromuscular disorder patients report their services to be at best 'average' and more often 'poor' in quality. Centralization of care to a small number of specialist centres to increase critical mass and thus improve the expertise of clinical teams has been recommended. A recent audit of unplanned hospital admissions for neuromuscular disorder patients has substantiated data from patient surveys. Patients often had no access to a neuromuscular specialist or had fragmented care; 37.5% of 359 unplanned neuromuscular disorder emergency admissions were identified as potentially avoidable. A Neuromuscular Complex Care Centre has recently opened in the United Kingdom to provide holistic patient-centred care in a purpose built adapted environment with high staff to patient ratio. Elective multisystem assessments will be co-ordinated into a 'one stop' admission, bringing the specialists to the patient. The centre will provide first point of contact with 24-h telephone access 7 days a week and will advise and support local hospitals on the management of acutely unwell patients. Regular multidisciplinary meetings of specialized consultants and therapists will improve communication and maximize outcomes. In the long term, we anticipate this high-quality development to be cost-effective in reducing the frequency of outpatient appointments and emergency/critical care admissions.

Teleoncology: Improving Patient Outcome Through Coordinated Care

There are few specialized oncology centers in Pakistan. Teleoncology was introduced for weekly tumor case meetings between the surgery departments of Holy Family Hospital and NORI Hospital using videoconferencing. The team of surgeons, radiologists, and histopathologists of Holy Family Hospital and the oncologists from NORI Hospital are now conducting joint regular multidisciplinary meetings weekly for the well-being of patients of the area. The purpose of this study is to describe the infrastructure, consultative process, technical aspects, and initial evaluation of these meetings. The surgical oncology patients are discussed every Friday morning since November 2009. A standardized format was adopted for case discussion in these multidisciplinary meetings. The postgraduate trainee presents the case from either side followed by management plan discussion. The oncologists may request a discussion to plan an intervention at Holy Family Hospital, or the surgeons at Holy Family Hospital may present a case that would benefit from multidisciplinary skills. In total, 264 patients were discussed. The mean age of the patients was 51±16.2 years. In 43% of the patients, the joint treatment strategy was refined from the initial proposed treatment. Breast and gastrointestinal tract malignancies were the most common cases, followed by endocrine and skin and soft tissue tumors. Teleoncology services can be extended easily with little addition to existing infrastructure but significantly reduce the stress for families as they deal with this challenging disease. Moreover, they improve the clinical evaluation and management strategies.

Improving time to antibiotics and implementing the "Sepsis 6".

It has been shown that completion of the “Sepsis 6” within 1 hour reduces mortality (1). This project aims to assess compliance with this standard and evaluate the effectiveness of a sepsis improvement plan in a district general hospital in the UK.A baseline audit was performed, examining case notes of “septic patients” retrospectively (those on intravenous antibiotics). Compliance with each element of the sepsis six plus time to first antibiotic (TTFA) was assessed. A sepsis improvement plan was introduced consisting of staff education, reinforcing vigilance, regular multidisciplinary meetings and incorporating a standardised approach through the use of a sepsis proforma. Following the introduction of this, and after some refinement, the average time to antibiotic fell from 6 hours to 1.4 hours.In conclusion, an educational drive along with a systematic change in processes has seen reduced TTFA along with enhanced compliance with most elements of the sepsis 6. Through continued assessment and further improving upon systematic processes with continued education we would anticipate consistent improvement in the management of septic patients.