Applying the lessons of design thinking: a unique programme of care for acutely unwell, community-dwelling COVID-19 patients.

BACKGROUND: The COVID-19 pandemic limited access to primary care and in-person assessments requiring healthcare providers to re-envision care delivery for acutely unwell outpatients. Design thinking methodology has the potential to support the robust evolution of a new clinical model. AIM: To demonstrate how design thinking methodology can rapidly and rigorously create and evolve a safe, timely, equitable and patient-centred programme of care, and to share valuable lessons for effective implementation of design thinking solutions to address complex problems. METHOD: We describe how design thinking methodology was employed to create a new clinical model of care. Using the example of a novel telemedicine programme to support acutely unwell, community-dwelling COVID-19-positive patients called the London Urgent COVID-19 Care Clinic (LUC3), we show how continuous quality outcomes (safety, timeliness, equity and patient-centredness), as well as patient experience survey responses, can drive iterative changes in programme delivery. RESULTS: The inspiration phase identified four key needs for this patient population: monitoring COVID-19 signs and symptoms; self-managing COVID-19 symptoms; managing other comorbidities in the setting of COVID-19; and escalating care as needed. Guided by these needs, a cross-disciplinary stakeholder group was engaged in the ideation and implementation phases to create a unique and comprehensive telemedicine programme (LUC3). During the implementation phase, LUC3 assessed 2202 community-based patients diagnosed with acute COVID-19; the collected quality outcomes and end-user feedback led to evolution of programme delivery. CONCLUSION: Design thinking methodology provided an essential framework and valuable lessons for the development of a safe, equitable, timely and patient-centred telemedicine care programme. The lessons learnt here-the importance of inclusive collaboration, using empathy to guide equity-focused interventions, leveraging continuous metrics to drive iteration and aiming for good-if-not-perfect plans-can serve as a road map for using design thinking for targeted healthcare problems.

Comparison of the major intraoperative and postoperative complications between unilateral and sequential bilateral total knee arthroplasty in a high-volume community hospital.

BACKGROUND: Total knee arthroplasty (TKA) is a common surgical treatment for arthritis. In the event of bilateral knee symptoms, a patient may elect for bilateral TKA (BTKA) under 1 anesthetic or 2 separate unilateral TKAs (UTKA). Controversy exists in the literature regarding the safety of BTKA versus UTKA. We compared the rate of major intraoperative and postoperative complications for BTKA versus UTKA at a high-volume community hospital. METHODS: We compared 373 patients who underwent BTKA with 966 who underwent UTKA between May 2008 and May 2011. Health records were used to determine patient characteristics and major intraoperative and postoperative complications. The BTKA and UTKA cohorts were matched for demographic characteristics and comorbidities with the exception of previous transient ischemic attack and previous knee surgery (UTKA > BTKA). RESULTS: Rates of intraoperative and postoperative complications, including cardiovascular, thromboembolic and neurologic complications; deep wound infections; and mortality, did not differ significantly between groups. Bilateral TKA was associated with a greater proportion of patients requiring blood transfusion than UTKA (29.8% v. 8.9%, p < 0.001). Among those transfused, there was no significant difference between the groups in the mean number of units required (1.72 ± 0.77 v. 1.53 ± 0.85 units, p = 0.68). CONCLUSION: Bilateral TKA was not associated with statistically greater rates of intraoperative and postoperative complications than UTKA, barring the proportion of patients requiring transfusion. Our results support the use of BTKA to treat bilateral knee arthritis in a high-volume community hospital setting.

CONTEXTE: La prothèse (ou arthroplastie) totale du genou (PTG) est un traitement chirurgical courant contre l'arthrite. Quand les 2 genoux sont atteints, le patient peut choisir entre une PTG bilatérale (PTGB), qui ne nécessitera qu'une seule anesthésie, ou 2 interventions unilatérales distinctes (PTGU). Dans la littérature, on ne semble pas s'entendre sur l'innocuité de la PTGB contre la PTGU. Nous avons comparé les taux de complications peropératoires et postopératoires majeures associées aux PTGB et aux PTGU dans un hôpital communautaire où s'effectue un volume élevé de telles interventions. MÉTHODES: Nous avons comparé 373 patients qui ont subi une PTGB à 966 qui ont subi une PTGU entre mai 2008 et mai 2011. Nous avons consulté les dossiers médicaux pour établir les caractéristiques des patients et relever les complications peropératoires et postopératoires majeures. Les cohortes soumises à la PTGB et à la PTBU ont été assorties en fonction des caractéristiques démographiques et des comorbidités, à l'exception des antécédents d'accidents ischémiques transitoires et d'interventions chirurgicales du genou (PTGU > PTGB). RÉSULTANTS: Les taux de complications peropératoires et postopératoires, y compris cardiovasculaires, thromboemboliques et neurologiques, les infections de plaies profondes et la mortalité n'ont pas varié significativement entre les groupes. Une proportion plus grande de patients soumis à la PTGB a nécessité une transfusion sanguine comparativement aux patients soumis à la PTGU (29,8 % c. 8,9 %, p < 0,001). Parmi les receveurs de transfusions, on n'a noté aucune différence significative entre les groupes quant au nombre moyen d'unités requises (1,72 ± 0,77 c. 1,53 ± 0,85 unité, p = 0,68). CONCLUSIONS: La PTGB n'a pas été associée à des taux statistiquement plus élevés de complications peropératoires et postopératoires comparativement à la PTGU, à l'exception de la proportion de patients ayant nécessité une transfusion. Nos résultats appuient le recours à la PTGB pour traiter l'arthrite bilatérale du genou dans le contexte d'un hôpital communautaire ou le volume de ces interventions est élevé.

Integrin alpha5beta1 function is regulated by XGIPC/kermit2 mediated endocytosis during Xenopus laevis gastrulation.

During Xenopus gastrulation alpha5beta1 integrin function is modulated in a temporally and spatially restricted manner, however, the regulatory mechanisms behind this regulation remain uncharacterized. Here we report that XGIPC/kermit2 binds to the cytoplasmic domain of the alpha5 subunit and regulates the activity of alpha5beta1 integrin. The interaction of kermit2 with alpha5beta1 is essential for fibronectin (FN) matrix assembly during the early stages of gastrulation. We further demonstrate that kermit2 regulates alpha5beta1 integrin endocytosis downstream of activin signaling. Inhibition of kermit2 function impairs cell migration but not adhesion to FN substrates indicating that integrin recycling is essential for mesoderm cell migration. Furthermore, we find that the alpha5beta1 integrin is colocalized with kermit2 and Rab 21 in embryonic and XTC cells. These data support a model where region specific mesoderm induction acts through kermit2 to regulate the temporally and spatially restricted changes in adhesive properties of the alpha5beta1 integrin through receptor endocytosis.