Role of family medicine physicians in providing nutrition support to older patients admitted to orthopedics departments: a grounded theory approach.

BACKGROUND: Care of older adults requires comprehensive management and control of systemic diseases, which can be effectively managed by family physicians. Complicated medical conditions in older patients admitted to orthopedic departments (orthopedic patients) necessitate interprofessional collaboration. Nutrition is one of the essential components of management involved in improving the systemic condition of older patients. Nutrition support teams play an important role in nutrition management and can be supported by family physicians. However, the role of family physicians in nutrition support teams is not well documented. This study aimed to investigate the role of family physicians in supporting nutrition management in orthopedic patients. METHODS: This qualitative study was conducted between January and June 2023 using constructivist grounded theory methodology. Eight family medicine physicians, three orthopedic surgeons, two nurses, two pharmacists, four rehabilitation therapists, four nutritionists, and one laboratory technician working in Japanese rural hospitals participated in the research. Data collection was performed through ethnography and semi-structured interviews. The analysis was performed iteratively during the study. RESULTS: Using a grounded theory approach, four theories were developed regarding family physicians' role in providing nutrition support to orthopedic patients: hierarchical and relational limitation, delay of onset and detection of the need for geriatric care in orthopedic patients, providing effective family medicine in hospitals, and comprehensive management through the nutrition support team. CONCLUSIONS: The inclusion of family physicians in nutrition support teams can help with early detection of the rapid deterioration of orthopedic patients' conditions, and comprehensive management can be provided by nutrition support teams. In rural primary care settings, family physicians play a vital role in providing geriatric care in community hospitals in collaboration with specialists. Family medicine in hospitals should be investigated in other settings for better geriatric care and to drive mutual learning among healthcare professionals.

Adjustments in Interprofessional Communication: A Focus Group Study in Psychiatric Outpatient Units.

Communication in healthcare extends beyond patient care, impacting the work environment and job satisfaction. Interprofessional communication is essential for fostering collaboration, but challenges arise from differences in training, roles, and hierarchies. The study aimed to explore psychiatric outpatient clinicians' experiences of interprofessional communication and their perceptions of how the communication intersects the organizational and social work environment of healthcare. Qualitative research involved focus group interviews with clinicians from five psychiatric outpatient units in Central Sweden, representing diverse professions. The authors analyzed semi-structured interview data thematically to uncover clinicians' perspectives on interprofessional communication. An overarching theme, "Adjustment of communication," with subthemes "Synchronized communication" and "Dislocated communication," emerged. Clinicians adapted communication strategies based on situations and needs, with synchronized communication promoting collaboration and dislocated communication hindering it. Communicating with each other was highly valued, as it contributed to a positive work environment. The study underscores the importance of an open, supportive environment that fosters trust, and respect among healthcare clinicians. Consistent with prior research, collaboration gaps underscore the urgent need to improve interprofessional communication.

Recreating the village: the patient experience with a hybrid model of Group Perinatal Care (GPPC) in an academic family health team.

BACKGROUND: Group prenatal care (GPC) has been shown to have a positive impact on social support, patient knowledge and preparedness for birth. We developed an interprofessional hybrid model of care whereby the group perinatal care (GPPC) component was co-facilitated by midwives (MW) and family medicine residents (FMR) and alternating individual visits were provided by family physicians (FP's) within our academic family health team (FHT) In this qualitative study, we sought to explore the impact of this program and how it supports patients through pregnancy and the early newborn period. METHODS: Qualitative study that was conducted using semi-structured telephone interviews with 18 participants who had completed GPPC in the Mount Sinai Academic Family Health Team in Toronto, Canada and delivered between November 2016 and October 2018. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted by team members using grounded theory. RESULTS: Four over-arching themes emerged from the data: (i) Participants highly valued information they received from multiple trusted sources, (ii) Participants felt well cared for by the collaborative and coordinated interprofessional team, (iii) The design of GPPC enabled a shared experience, allowing for increased support of the pregnant person, and (iv) GPPC facilitated a supportive transition into the community which positively impacted participants' emotional well- being. CONCLUSIONS: The four constructs of social support (emotional, informational, instrumental and appraisal) were central to the value that participants found in GPPC. This support from the team of healthcare providers, peers and partners had a positive impact on participants' mental health and helped them face the challenges of their transition to parenthood.

Healthcare team resilience during COVID-19: a qualitative study.

BACKGROUND: Resilience, in the field of Resilience Engineering, has been identified as the ability to maintain the safety and the performance of healthcare systems and is aligned with the resilience potentials of anticipation, monitoring, adaptation, and learning. In early 2020, the COVID-19 pandemic challenged the resilience of US healthcare systems due to the lack of equipment, supply interruptions, and a shortage of personnel. The purpose of this qualitative research was to describe resilience in the healthcare team during the COVID-19 pandemic with the healthcare team situated as a cognizant, singular source of knowledge and defined by its collective identity, purpose, competence, and actions, versus the resilience of an individual or an organization. METHODS: We developed a descriptive model which considered the healthcare team as a unified cognizant entity within a system designed for safe patient care. This model combined elements from the Patient Systems Engineering Initiative for Patient Safety (SEIPS) and the Advanced Team Decision Making (ADTM) models. Using a qualitative descriptive design and guided by our adapted model, we conducted individual interviews with healthcare team members across the United States. Data were analyzed using thematic analysis and extracted codes were organized within the adapted model framework. RESULTS: Five themes were identified from the interviews with acute care professionals across the US (N = 22): teamwork in a pressure cooker, consistent with working in a high stress environment; healthcare team cohesion, applying past lessons to present challenges, congruent with transferring past skills to current situations; knowledge gaps, and altruistic behaviors, aligned with sense of duty and personal responsibility to the team. Participants' described how their ability to adapt to their environment was negatively impacted by uncertainty, inconsistent communication of information, and emotions of anxiety, fear, frustration, and stress. Cohesion with co-workers, transferability of skills, and altruistic behavior enhanced healthcare team performance. CONCLUSION: Working within the extreme unprecedented circumstances of COVID-19 affected the ability of the healthcare team to anticipate and adapt to the rapidly changing environment. Both team cohesion and altruistic behavior promoted resilience. Our research contributes to a growing understanding of the importance of resilience in the healthcare team. And provides a bridge between individual and organizational resilience.

[Patient motivation and prehabilitation: assessment often overlooked]. / Motivation du patient et préhabilitation : l'évaluation souvent oubliée.

Prehabilitation, which is still in its infancy, is becoming an essential part of oncology treatment. Motivation assessment is crucial for adherence to these programs, which aim to optimize functional capacity before and during the intensive phases of treatment. To date, healthcare teams have had little experience of assessing motivation, which is a weakness in the care strategy. This is partly due to a lack of standardized models and a delay in caregivers changing their position in response to changes in patient' motivations. In this article, we invite to discuss the 'why' and 'how' of motivational assessment in patients undergoing prehabilitation.

Improving Medication Management for Inpatients with a Secondary Diagnosis of Parkinson Disease.

ABSTRACT: Patients who have Parkinson disease require individualized medication regimens to optimize care. A review of the medication management of patients admitted to a tertiary care hospital with a secondary diagnosis of Parkinson disease found significant departures from the patients' home regimen. Medication regimens are often altered by health care teams unfamiliar with Parkinson disease-specific care in order to conform to standard hospital medication orders and administration times, potentially resulting in increased patient falls, delirium, and mortality.A nurse-led multidisciplinary team consisting of pharmacy, nursing, informatics, neurology, and quality personnel implemented a quality improvement (QI) project between July 2020 and July 2022 to identify patients with Parkinson disease, including those with a secondary diagnosis and those undergoing deep brain stimulation, and customize medication management in order to reduce length of stay, mortality, falls, falls with harm, and 30-day readmissions. The QI project team also evaluated patient satisfaction with medication management.Among patients with a secondary diagnosis of Parkinson disease, the proportion who had medication histories conducted by a pharmacy staff member increased from a baseline of 53% to more than 75% per month. For all patients with Parkinson disease, those whose medication history was taken by a pharmacy staff member had orders matching their home regimen 89% of the time, whereas those who did not had orders matching the home regimen only 40% of the time. Among patients with a secondary diagnosis of Parkinson disease, the length-of-stay index decreased from a baseline of 1 to 0.94 and observed-to-expected mortality decreased from 1.03 to 0.78. The proportion of patients experiencing a fall decreased from an average of 5% to 4.08% per quarter, while the proportion of patients experiencing a fall with harm decreased from an average of 1% to 0.75% per quarter. The rate of 30-day readmissions decreased from 10.81% to 4.53% per quarter. Patient satisfaction scores were 1.95 points higher for patients who had medication histories taken by pharmacy than for those who did not (5 versus 3.05).

Non-dispensing pharmacists integrated into general practices as a new interprofessional model: a qualitative evaluation of general practitioners' experiences and views.

BACKGROUND: A new interprofessional model incorporating non-dispensing pharmacists in general practice teams can improve the quality of pharmaceutical care. However, results of the model are dependent on the context. Understanding when, why and how the model works may increase chances of successful broader implementation in other general practices. Earlier theories suggested that the results of the model are achieved by bringing pharmacotherapeutic knowledge into general practices. This mechanism may not be enough for successful implementation of the model. We wanted to understand better how establishing new interprofessional models in existing healthcare organisations takes place. METHODS: An interview study, with a realist informed evaluation was conducted. This qualitative study was part of the Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in primary care Teams (POINT) project. We invited the general practitioners of the 9 general practices who (had) worked closely with a non-dispensing pharmacist for an interview. Interview data were analysed through discussions about the coding with the research team where themes were developed over time. RESULTS: We interviewed 2 general practitioners in each general practice (18 interviews in total). In a context where general practitioners acknowledge the need for improvement and are willing to work with a non-dispensing pharmacist as a new team member, the following mechanisms are triggered. Non-dispensing pharmacists add new knowledge to current general practice. Through everyday talk (discursive actions) both general practitioners and non-dispensing pharmacists evolve in what they consider appropriate, legitimate and imaginable in their work situations. They align their professional identities. CONCLUSIONS: Not only the addition of new knowledge of non-dispensing pharmacist to the general practice team is crucial for the success of this interprofessional healthcare model, but also alignment of the general practitioners' and non-dispensing pharmacists' professional identities. This is essentially different from traditional pharmaceutical care models, in which pharmacists and GPs work in separate organisations. To induce the process of identity alignment, general practitioners need to acknowledge the need to improve the quality of pharmaceutical care interprofessionally. By acknowledging the aspect of interprofessionality, both general practitioners and non-dispensing pharmacists will explore and reflect on what they consider appropriate, legitimate and imaginable in carrying out their professional roles. TRIAL REGISTRATION: The POINT project was pre-registered in The Netherlands National Trial Register, with Trial registration number NTR-4389.

Care complexity, perceptions of complexity and preferences for interprofessional collaboration: an analysis of relationships and social networks in paediatrics.

BACKGROUND: In the context of increasingly intricate healthcare systems, professionals are compelled to collaborate within dynamically changing interprofessional teams. Moreover, they must adapt these collaborative processes to effectively and efficiently manage the evolving complexity of care needs. It remains unclear how professionals determine care complexity and relate this complexity to their preferences for interprofessional collaboration (IPC). This study investigated the relationships between care complexity, professionals' perceived complexity and IPC preferences, and examined the variation in individual and team characteristics of IPC-practices across different levels of complexity in paediatric care. METHODS: In an online questionnaire, 123 healthcare professionals working at an academic tertiary children's hospital scored their perceptions of complexity and preferences for IPC. They also selected family and various professions as members of the interprofessional (IP-) team based on thirteen patient cases. We employed conjoint analysis to systematically model the complexity of case descriptions across the five domains of the International Classification of Functioning, Disability and Health (ICF). Additionally, we applied social network analysis to identify important professions, crucial connectors and influential professions in the IP-team, and to describe the cohesiveness of IP-teams. RESULTS: Modelled case complexity, professionals' perceived complexity and IPC preferences were positively associated. We found large inter-individual variations in the degree of these associations. Social network analysis revealed that the importance and influence of professions was more equally distributed when case complexity increased. Depending on the context and complexity of the case, different professions (e.g. medical doctors, social professionals, extramural professionals) were considered to be more crucial connectors within the IP-team. Furthermore, team cohesion was positively associated with modelled and perceived care complexity. CONCLUSIONS: In conclusion, our study contributes to the existing knowledge by integrating task-specific insights and broadening the use of conjoint and social network analysis in the context of IPC. The findings substantiate the contingency theory that relates characteristics of IPC to care complexity, offering quantified insights into how IP-teams adapt to situational needs. This understanding of relationships and variations within IPC holds crucial implications for designing targeted interventions in both clinical and health profession education contexts. Consequently, it contributes to advancements in healthcare systems.

A case report of an atypical severe case of skin picking disorder managed by a multidisciplinary team.

BACKGROUND: While skin picking disorder remains relatively common, it often does not present to psychiatry until significant morbidity or comorbidities are reached. It is described as recurrent picking of skin leading to skin lesions, with repeated attempts to decrease or stop skin picking. It is also often associated with significant distress or functional impairment. There has been limited research in this specific disorder and treatment efficacy has often been poor in severe cases. For various reasons, only a small amount of patients with this disorder present to care, and often to a multidisciplinary team prior to psychiatry. CASE PRESENTATION: This is a case presentation of a 44 year old male with a complex past psychiatric history, ultimately untreated for an underlying skin picking disorder. He presented for urgent medical care following a self-inflicted wound through the central frontal bone and dura over the course of 2 years. He was treated with current psychiatric evidence based medicine, including an SSRI, antipsychotic augmentation and NAC, along with habit reversal techniques during the admission. He was concurrently managed with the neurosurgery team, initially with a poor prognosis due to the severity of his presentation. He required debriding of the devitalized bone within the adjacent brain to cover the dural defect, IV antibiotics for 6 weeks, and an initial skin graft on his initial admission. CONCLUSIONS: This case in particular highlighted the importance of urgent treatment via a multidisciplinary approach to avoid mortality. It highlights the importance of increasing awareness about the disorder and that treatment with SSRI's, along with antipsychotic and NAC adjuncts remains the mainstay of acute treatment.

Medicolegal aspects of documentation and the electronic health record.

INTRODUCTION: The busiest times in the hospital are often met by the greatest challenges in complete and comprehensive documentation of the patient care event. The near complete transition to the Electronic Health Record (EHR) was to be the solution to a host of provider documentation concerns. It is clear the EHR provides reliability, reproducibility, integration, evidence based decision-making, multidisciplinary contribution across the entire healthcare spectrum. METHODS: The use of a consensus of expert opinion supplemented by focused literature review allows a balanced evidence based presentation of data. RESULTS: Documentation is not a perfect tool however, as issues with efficiency, reliability, use of shortcut maneuvers and potential for increased medico-legal risk have been raised. The solution is attention to documentation detail, and creation of systems that facilitate excellence. The focus on electronic documentation systems should include continual evaluation, ongoing improvement, involvement of a multidisciplinary patient care team and vendor receptiveness to in EHR development and operations. CONCLUSION: The most effective use of the EHR as a risk management tool requires documentation knowledge, targeted analysis, product improvement and co-development of clinical-commercial resource.

Factors influencing interprofessional collaboration in general and during multidisciplinary team meetings in long-term care and geriatric rehabilitation: a qualitative study.

BACKGROUND: Interprofessional collaboration is essential to maintain high-quality care in long-term care and geriatric rehabilitation. However, little is known regarding perceived factors influencing interprofessional collaboration by people involved in care. This concerns both long-term care and geriatric rehabilitation. Moreover, knowledge of using patient outcome measures to enhance interprofessional collaboration during multidisciplinary team meetings is insufficient. This study examined the perceived facilitators of and barriers to interprofessional collaboration in general and during multidisciplinary team meetings, specifically according to healthcare professionals, patients, and informal caregivers. Differences between long-term care and geriatric rehabilitation were also investigated. Finally, it was examined which patient outcome measures were used in multidisciplinary team meetings. METHODS: A constructivist qualitative study using 10 focus groups and 18 semi-structured interviews with 14 patients, 13 informal caregivers,10 managers, and 22 healthcare professionals from eight Dutch long-term care and geriatric rehabilitation facilities. A combined inductive and deductive approach to a thematic analysis was performed. RESULTS: The perceived influencing factors of interprofessional collaboration were classified into two general themes: (1) 'Involvement of patient, informal caregiver, and healthcare professional', categorised into: 'participation of patients and informal caregivers', 'behaviour and attitude of team members', 'expectations of team members towards each other', and 'exchange of information, knowledge, and reciprocity in communication'; and (2) 'A systematic approach to providing care for older people', consisting of: 'coordination of team procedures', and 'coordination of organisational procedures'. Also, one theme for multidisciplinary team meetings was identified: 'Organised participation of patient, informal caregiver, and healthcare professional in multidisciplinary team meeting, categorised into: 'team procedures', 'working systematically', and 'participation in multidisciplinary team meetings. Standardised patient outcome measures were scarcely used in multidisciplinary team meetings. CONCLUSION: People involved in long-term care and geriatric rehabilitation indicated that, apart from working systematically, being involved in care and multidisciplinary team meetings are essential factors for interprofessional collaboration. These factors must be taken into consideration to provide valuable, high-quality care to older people residing in long-term care and geriatric. TRIAL REGISTRATION: Not applicable.

Clinical efficacy analysis of surgical treatment for spinal metastasis under the multidisciplinary team using the NOMS decision system combined with the revised Tokuhashi scoring system: a randomized controlled study.

OBJECTIVE: Despite advancements in spinal metastasis surgery techniques and the rapid development of multidisciplinary treatment models, we aimed to explore the clinical efficacy of spinal metastasis surgery performed by a combined NOMS decision system-utilizing multidisciplinary team and Revised Tokuhashi scoring system, compared with the Revised Tokuhashi scoring system. METHODS: Clinical data from 102 patients with spinal metastases who underwent surgery at three affiliated hospitals of Zunyi Medical University from December 2017 to June 2022 were analysed. The patients were randomly assigned to two groups: 52 patients in the treatment group involving the combined NOMS decision system-utilizing multidisciplinary team and Revised Tokuhashi scoring system (i.e., the combined group), and 50 patients in the treatment group involving the Revised Tokuhashi scoring system only (i.e., the revised TSS-only group). Moreover, there were no statistically significant differences in preoperative general data or indicators between the two groups. Intraoperative and postoperative complications, average hospital stay, mortality rate, and follow-up observation indicators, including the visual analogue scale (VAS) score for pain, Eastern Cooperative Oncology Group (ECOG) performance status, Karnofsky Performance Status (KPS) score, negative psychological assessment score (using the Self-Rating Anxiety Scale, [SAS]), and neurological function recovery score (Frankel functional classification) were compared between the two groups. RESULTS: All 102 patients successfully completed surgery and were discharged. The follow-up period ranged from 12 to 24 months, with an average of (13.2 ± 2.4) months. The patients in the combined group experienced fewer complications such as surgical wound infections 3 patients(5.77%), intraoperative massive haemorrhage 2 patients(3.85%), cerebrospinal fluid leakage 2 patients(3.85%), deep vein thrombosis 4 patients(7.69%),and neurological damage 1 patient(1.92%), than patients in the revised TSS-only group (wound infections,11 patients(22%); intraoperative massive haemorrhage, 8 patients(16%);cerebrospinal fluid leakage,5 patients(10%);deep vein thrombosis,13 patients (26%); neurological damage,2 patients (4%). Significant differences were found between the two groups in terms of surgical wound infections, intraoperative massive haemorrhage, and deep vein thrombosis (P < 0.05). The average postoperative hospital stay in the combined group (7.94 ± 0.28 days) was significantly shorter than that in the revised TSS-only group (10.33 ± 0.30 days) (P < 0.05). Long-term follow-up (1 month, 3 months, 6 months, and 1 year postoperatively) revealed better clinical outcomes in the combined group than in the revised TSS-only group in terms of VAS scores, overall KPS%, neurological function status Frankel classification, ECOG performance status, and SAS scores.(P < 0.05). CONCLUSION: A multidisciplinary team using the NOMS combined with the Revised Tokuhashi scoring system for spinal metastasis surgery showed better clinical efficacy than the sole use of the Revised Tokuhashi scoring system. This personalized, precise, and rational treatment significantly improves patient quality of life, shortens hospital stay, reduces intraoperative and postoperative complications, and lowers mortality rates.