Experience from a Singapore tertiary hospital with restructuring of a vascular surgery practice in response to national and institutional policies during the COVID-19 pandemic.

Singapore was one of the first countries to be affected by COVID-19, with the index patient diagnosed on January 23, 2020. For 2 weeks in February, we had the highest number of COVID-19 cases behind China. In this article, we summarize the key national and institutional policies that were implemented in response to COVID-19. We also describe in detail, with relevant data, how our vascular surgery practice has changed because of these policies and COVID-19. We show that with a segregated team model, the vascular surgery unit can still function while reducing risk of cross-contamination. We explain the various strategies adopted to reduce outpatient and inpatient volume. We provide a detailed breakdown of the type of vascular surgical cases that were performed during the COVID-19 pandemic and compare it with preceding months. We discuss our operating room and personal protective equipment protocols in managing a COVID-19 patient and share how we continue surgical training amid the pandemic. We also discuss the challenges we might face in the future as COVID-19 regresses.

The multi-disciplinary team - Who is liable when things go wrong?

The question of culpability over decisions made by the multi-disciplinary team (MDT) is a contentious one. Currently, all members present remain responsible for the MDT's decision, but it is unclear whether the onus of decision making lies with the patient's "lead clinician", and how straight to test pathways (bypassing a consultation with a specialist prior to MDT discussion) impact on this. Additionally, should a non-consensus recommendation be reached, it remains undetermined how dissenting members of the MDT would be viewed in a court of law. Given these uncertainties, there remains a substantial risk of legal action against the MDT as a group. Until case law materialises to provide clarification on these issues, clinicians should improve their awareness over their medico-legal responsibilities and proceed with caution.

The Helsinki approach to face transplantation.

AIM: We herein describe the establishment of the Helsinki Vascularized Composite Allotransplantation (VCA) program and its execution in the first two face transplant cases. METHODS & PATIENTS: The Helsinki VCA program initially required the fulfillment of legal, hospital, financial, and ethical requirements. Thereafter, the assembling of a multidisciplinary team commenced. A team of Plastic, maxillofacial and ENT surgeons comprise the facial VCA team. The protocol involves collaboration with the Solid Organ Transplant (SOT) team, transplant immunology, immunosuppression, microbiology, psychiatric evaluation, well-defined VCA indications and informed consent. Between 2011 and 2017 two patients were selected for transplantation. Both patients had a severe composite facial deformity involving the maxilla and mandible following earlier ballistic injury. RESULTS: Patient 1 was a 35 year-old male who underwent successful near total face transplantation in February 2016 and at 30 months he has a good aesthetic outcome with symmetrical restoration of the central face and good sensory and symmetrical motor functional outcomes. Patient 2 was a 58 year-old male who underwent full face transplantation in March 2018 and at 5 months he has recovered without major problems. CONCLUSION: A successful facial VCA program requires a well-prepared research protocol, experts from multiple specialties and careful patient selection. The establishment of the Helsinki VCA program required long and thorough planning and resulted in the first two Nordic face transplantation cases. This protocol now forms the platform (as a proof of concept) for other types of vascularized composite allotransplantations.

Is the team leading surgeon criminally liable for his collaborators' errors? Judges confirm responsibility and condemn an otorhinolaryngologist.

SUMMARY: In current healthcare, delivery of medical and surgical treatment takes place in a multidisciplinary manner. This raises the problem of distinguishing the conditions under which the person who has properly carried out his duties, respecting the related leges artis, can be held responsible for damages materially caused by another member of the medical team. Jurisprudence has developed the so-called "principle of trust" for which every member of the team can rely on the fact that other members are acting in compliance with the leges artis of their specialisation. The Supreme Court has limited the application of this principle. The authors examine the jurisprudence on responsibility of the team in otolaryngology and conclude that individual liability should be limited to the specific expertise of the individual specialist.

[The latest best practice guidelines relating to seclusion and restraint]. / Les dernières recommandations de bonnes pratiques sur l'isolement et la contention.

Several measures relating to seclusion and restraint are included in the French public health code. The best practice guidelines of the French National Health Authority, published in 2017, define these two notions and advise on the behaviour to adopt with regard to their implementation and monitoring. Likewise, informing and supporting the patient when these measures are lifted are critical moments which the teams must also be able to manage correctly.

Are multidisciplinary teams a legal shield or just a clinical comfort blanket?

Discussion about and management of patients through multidisciplinary team meetings has become the standard of care in medical and surgical specialties, but does the team nature of these provide a legal shield for clinicians? This article discusses the legal implications of decision making within a multidisciplinary team.

[The ward round of the future ­ a person-centred, team-based meeting with the patient]. / Framtidens rond ­ ett personcentrerat och teambaserat möte med patienten - Den traditionella ronden går inte att försvara etiskt eller juridiskt.

The aim of this article is to elucidate the traditional ward round from an historical, ethical and legal perspective. On the traditional ward round in hospitals, a senior clinician leads a group of other clinicians and health professionals on a walking tour through the ward to visit the patients for whom they are responsible at bedside. It is a long-lived tradition or routine, which has been substantially resistant to change. We recommend that work designed to improve the ward round should begin from values or ethical principles, such as respecting the patient's integrity and right to participate in decision-making. Moreover, the focal point should be creating opportunities for ¼the good meeting« and patient narratives. A team-based, person-centred ward round has been implemented in some hospitals in Sweden. The patient meets the ward team in a separate room to discuss the plan of care together. We argue that it is no longer possible to defend the traditional way of walking rounds, either ethically or legally.

Effect of enhanced feedback to hospitals that are part of an emerging clinical information network on uptake of revised childhood pneumonia treatment policy: study protocol for a cluster randomized trial.

BACKGROUND: The national pneumonia treatment guidelines in Kenya changed in February 2016 but such guideline changes are often characterized by prolonged delays in affecting practice. We designed an enhanced feedback intervention, delivered within an ongoing clinical network that provides a general form of feedback, aimed at improving and sustaining uptake of the revised pneumonia treatment policy. The objective was to determine whether an enhanced feedback intervention will improve correctness of classification and treatment of childhood pneumonia, compared to an existing approach to feedback, after nationwide treatment policy change and within an existing hospital network. METHODS/DESIGN: A pragmatic, cluster randomized trial conducted within a clinical network of 12 Kenyan county referral hospitals providing inpatient pediatric care to children (aged 2-59 months) with acute medical conditions between March and November 2016. The intervention comprised enhanced feedback (monthly written feedback incorporating goal setting, and action planning delivered by a senior clinical coordinator for selected pneumonia indicators) and this was compared to standard feedback (2-monthly written feedback on multiple quality of pediatric care indicators) both delivered within a clinical network promoting clinical leadership linked to mentorship and peer-to-peer support, and improved use of health information on service delivery. The 12 hospitals were randomized to receive either enhanced feedback (n = 6) or standard feedback (n = 6) delivered over a 9-month period following nationwide pneumonia treatment policy change. The primary outcome is the proportion of all admitted patients with pneumonia (fulfilling criteria for treatment with orally administered amoxicillin) who are correctly classified and treated in the first 24 h. The secondary outcome will be measured over the course of the admission as any change in treatment for pneumonia after the first 24 h. DISCUSSION: This trial protocol employs a pragmatic trial design during a period of nationwide change in treatment guidelines to address two high-priority areas within implementation research: promoting adoption of health policies and optimizing effectiveness of feedback. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02817971 . Registered retrospectively on 27 June 2016.

[The commission/comprehensive forensic medical expertise with the participation of the medical professionals]. / Sudebnaia komissionnaia/kompleksnaia ékspertiza s uchastiem vrachei.

The present article deals with the categorization of the forensic medical expertises with respect to their ranking as commission and/or comprehensive ones. The arguments for and against such an approach and interpretation are presented.

[Surgeons-anesthetists relations: From an individual responsibility of the surgeon to a shared responsibility with the anesthetist]. / Relations chirurgiens/anesthésistes-réanimateurs : d'une responsabilité individuelle du chirurgien à une responsabilité partagée avec l'anesthésiste-réanimateur.

Throughout the perioperative period, anesthetists and surgeons jointly provide care for patients. The advances in medicine and surgery, the practice of perioperative quality medicine and the recent application of enhanced recovery program after surgery have necessitated strengthening the place of each in its area of expertise while developing the spirit team and communication. Thus, alongside the surgeon who was once considered the head of the surgical team, the anesthetist's role has been to consolidate for the management of the surgical patient and had his spot empower themselves in the eye of the patient with the birth an own contract with the patient (due in particular to the obligation to preanesthetic consultation by the decree of December 5, 1994). This has led to a new division of responsibility between these actors: jurisprudence has abandoned the exclusive responsibility of the surgeon, devoted own responsibility of the anesthetist with a division (if any) of responsibility between the anesthetist and the surgeon.

[Cooperation according to French Law "hospital, patients, health and territories": Pharmacists' involvement in Aquitaine region]. / Missions de coopération introduites par la loi « hôpital, patients, santé et territoires ¼ : participation des pharmaciens d'officine en Aquitaine.

BACKGROUND: In 2009, the French Act "Hospital, Patients, Health and Territories" (loi "Hôpital, Patients, Santé et Territoires") reorganized the outpatient care pathway and defined missions aimed at improving cooperation between pharmaceutical and medical professionals. Five years later, we conducted a survey among community pharmacists in order to assess the appropriation of these missions and the way cooperation was implemented. We also aimed to investigate factors that could hamper or ease the development of these activities in order to identify actions needed to improve pharmacists' involvement. METHODS: In partnership with the local health authorities "Agence régionale de santé", we conducted a survey via an online questionnaire sent to pharmacy holders in July 2014 in Aquitaine region. Information was collected about the pharmacies, involvement in collaborative activities, and barriers to cooperation. RESULTS: Overall, 20% (249) of pharmacists responded to the survey. They owned predominantly rural pharmacies (46%) or neighborhood pharmacies (41%), with two pharmacists per pharmacy (48%). Regarding collaborative activities, the majority of pharmacists (78%) had conducted interviews with their patients taking vitamin K antagonist therapy and they were willing to continue (87%). The implication was less common concerning other actions such as referent pharmacist for nursing homes (19%) or activities relating to therapeutic educational programs for patients with chronic conditions (34%). The vast majority of respondents (85%) were not aware of opportunities to become a correspondent pharmacist. The main obstacles for engaging in these activities were the lack of time, lack of knowledge about these missions and the lack of remuneration. We identified differences in pharmacists' involvement in collaborative activities depending on selected characteristics of the pharmacies. CONCLUSION: The findings of this survey underlined pharmacists' acceptance of these missions and suggest that better information and appropriate remuneration could enhance commitment. Recent changes in the legal framework (establishment of "pharmaceutical fees", extension of the scope of pharmaceutical interviews) enable funding for collaborative practices between medical practitioners and pharmacists, thus encouraging better coordination in the patient care pathway.

[Therapeutic approaches in court-ordered therapy]. / Les approches thérapeutiques dans l'injonction de soins.

As is the case with other contexts of mental health treatments, the therapeutic approaches to court-ordered therapy are varied. They are based on the principle of their clinical indication and must be delivered by therapists trained in the specific area. The classic therapeutic approaches are used: medication, psychoanalysis and psychoanalytically inspired therapies, cognitive behavioural therapies, group therapies and body-oriented approach.

[The shared nursing function]. / La fonction soignante en partage.

The Chair of Philosophy at Hôtel-Dieu hospital in Paris, is a place for the sharing of knowledge and recognition. It provides a place where the subjective, institutional and political dimension of care can be considered, by all stakeholders: patients, nurses, families and citizens. The aim is to invent a shared nursing function.

Multidisciplinary perioperative protocol in patients undergoing acute high-risk abdominal surgery.

BACKGROUND: Acute high-risk abdominal (AHA) surgery carries a very high risk of morbidity and mortality and represents a massive healthcare burden. The aim of the present study was to evaluate the effect of a standardized multidisciplinary perioperative protocol in patients undergoing AHA surgery. METHODS: The AHA study was a prospective single-centre controlled study in consecutive patients undergoing AHA surgery, defined as major abdominal pathology requiring emergency laparotomy or laparoscopy including reoperations after elective gastrointestinal surgery. Consecutive patients were included after initiation of the AHA protocol as standard care. The intervention cohort was compared with a predefined, consecutive historical cohort of patients from the same department. The protocol involved continuous staff education, consultant-led attention and care, early resuscitation and high-dose antibiotics, surgery within 6 h, perioperative stroke volume-guided haemodynamic optimization, intermediate level of care for the first 24 h after surgery, standardized analgesic treatment, early postoperative ambulation and early enteral nutrition. The primary outcome was 30-day mortality. RESULTS: Six hundred patients were included in the study and compared with 600 historical controls. The unadjusted 30-day mortality rate was 21·8 per cent in the control cohort compared with 15·5 per cent in the intervention cohort (P = 0·005). The 180-day mortality rates were 29·5 and 22·2 per cent respectively (P = 0·004). CONCLUSION: The introduction of a multidisciplinary perioperative protocol was associated with a significant reduction in postoperative mortality in patients undergoing AHA surgery. NCT01899885 (http://www.clinicaltrials.gov).