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.

Inpatient Flow Distribution Patterns at Shanghai Hospitals.

Empirical studies based on patient flow data are needed to provide more materials to summarize the general pattern of patient distribution models. This study takes Shanghai as an example and tries to demonstrate the inpatient flow distribution model for different levels and specialties of medical institutions. Power, negative exponential, Gaussian, and log-logistic models were used to fit the distributions of inpatients, and a model of inpatient distribution patterns in Shanghai was derived, based on these four models. Then, the adjusted coefficient of determination (R2) and Akaike information criterion (AIC) values were used to assess the model fitting effect. The log-logistic function model has a good simulation effect and the strongest applicability in most hospitals. The estimated value of the distance-decay parameter ß in the log-logistic function model is 1.67 for all patients, 1.89 for regional hospital inpatients, 1.40 for tertiary hospital inpatients, 1.64 for traditional Chinese medicine hospital inpatients, and 0.85 for mental hospital inpatients. However, the simulations at the tumor, children's and maternity hospitals, were not satisfactory. Based on the results of empirical analysis, the four attenuation coefficient models are valid in Shanghai, and the log-logistic model of the inpatient distributions at most hospitals have good simulation effects. However, further in-depth analysis combined with the characteristics of specific specialties is needed to obtain the inpatient model in line with the characteristics of these specialties.

Implementing and sustaining an evidence-based nutrition service in a haematology unit for autologous stem cell transplant patients.

PURPOSE: Effective, timely and evidence-based nutritional management is important in patients receiving autologous haematopoietic stem cell transplant (HSCT) to prevent the negative consequences of developing malnutrition. This study describes a robust process for development and implementation of an evidence-based nutrition care pathway for HSCT patients in a tertiary cancer centre. METHODS: A comprehensive review of the literature was completed to identify relevant articles and evidence-based guidelines to inform the development of the pathway. Evidence from the literature review was assessed and utilised to underpin the development of pathway. The pathway was implemented in the haematology service in collaboration with the multidisciplinary haematology team. Dietetic resource requirements for implementation of the pathway were determined and clinician compliance with the care pathway was assessed to evaluate the feasibility of the pathway in supporting delivery of evidence-based care. RESULTS: The evidence-based care pathway was implemented in 2011 with the final care pathway based on recommendations from five international evidence-based guidelines. Overall clinician compliance with delivering nutrition management described in the care pathway was high at 84%. The dietetic resource requirement for implementation of the care pathway was 300 to 400 h per 100 patients depending on conditioning chemotherapy regimen. CONCLUSION: A robust process for developing and implementing a nutrition care pathway for HSCT patients was effective in supporting the delivery of evidence-based nutritional management for patients treated with HSCT.

Multidisciplinary Clinics in Lung Cancer Care: A Systematic Review.

Multidisciplinary cancer clinics (MDCCs) are recognized in cancer care as an alternate model of care for lung cancer patients. However, the precise MDCC characteristics that could potentially improve the quality of care in lung cancer care have not been clearly defined. We performed a systematic review of the data regarding MDCCs in the treatment of patients with lung cancer to summarize and evaluate the available evidence and to determine valuable clinic characteristics and projected outcomes. We searched Embase, Cochrane, Medline, PubMed, and Web of Science through April 2017 for studies that included ≥ 2 physician specialties in a MDCC for lung cancer. A total of 2374 unique articles were identified, of which 13 met the inclusion criteria. All the studies were either retrospective or qualitative, with many having small sample sizes. The most commonly reported quantitative outcome for MDCCs was a decreased time from diagnosis to treatment; however, this was only statistically significant in 2 studies. Evidence was conflicting regarding improved patient survival. Several studies of MDCCs reported improved qualitative outcomes, including increased patient satisfaction, increased collaboration, and cohesive communication among care providers, although the sample sizes were small. The few studies of MDCCs that included a care coordinator, in addition to physicians from multiple specialties, reported improvements in patient satisfaction. Overall, our review of the reported data revealed a paucity of evidence regarding the value of MDCCs for lung cancer patients, highlighting the need for further studies to understand the optimal medical model to deliver care.

[Construction of Research-Oriented State Key Clinical Department by Highlighting the Characteris- tics and Advantages of Chinese Medicine].

As the largest research-oriented specialty department in national traditional Chinese medicine hospitals, the Department of Critical Care Medicine in Guangdong Provincial Hospital of Chinese Medicine insists on the development mode combined with clinical medicine and scientific research. By taking clinical and basic researches for integrative medicine preventing and treating acute myocardial in-farction and sepsis as a breakthrough, authors explored key problems of Chinese medicine in improving the prognosis related diseases and patients' quality of life. In recent 3 years our department has successively become the principal unit of the national key specialties cooperative group of critical care medicine (awarded by State Administration of Traditional Chinese Medicine), the key clinical specialties (awarded by National Health and Family Planning Commission), and Guangzhou key laboratory construction unit, and achieved overall lap in clinical medical treatment, personnel training, scientific research, and social service.

[How to convince the head of department and managing director of the importance of specialised headache clinics]. / Como convencer al jefe de servicio y al gerente de la importancia de las unidades/consultas especializadas de cefaleas.

In spite that headache is, by far, the most frequent reason for neurological consultation and that the diagnosis and treatment of some patients with headache is difficult, the number of headache clinics is scarce in our country. In this paper the main arguments which should allow us, as neurologists, to defend the necessity of implementing headache clinics are reviewed. To get this aim we should first overcome our internal reluctances, which still make headache as scarcely appreciated within our specialty. The facts that more than a quarter of consultations to our Neurology Services are due to headache, that there are more than 200 different headaches, some of them actually invalidating, and the new therapeutic options for chronic patients, such as OnabotulinumtoxinA or neuromodulation techniques, oblige us to introduce specialised headache attendance in our current neurological offer. Even though there are no definite data, available results indicate that headache clinics are efficient in patients with chronic headaches, not only in terms of health benefit but also from an economical point of view.

TITLE: Como convencer al jefe de servicio y al gerente de la importancia de las unidades/consultas especializadas de cefaleas.A pesar de que la cefalea es, con diferencia, el principal motivo neurologico de consulta, y de la complejidad diagnostica y terapeutica de algunos pacientes, el numero de consultas monograficas de cefalea (CC) y de unidades de cefalea (UC) es muy reducido en nuestro pais. En este articulo pasaremos revista a los principales argumentos que nos permitan, como neurologos, defender la necesidad de la implementacion de una CC/UC, dependiendo de la poblacion que se debe atender, en todos nuestros servicios de neurologia. Para ello deberemos, en primer lugar, vencer las reticencias internas, que hacen que la cefalea sea aun poco apreciada y atractiva dentro de nuestra especialidad. El hecho de que la cefalea justifique mas de un cuarto de las consultas a un servicio de neurologia estandar de nuestro pais y de que existan mas de 200 cefaleas diferentes, algunas de ellas realmente invalidantes, y las nuevas opciones de tratamiento para pacientes cronicos, como la OnabotulinumtoxinA para la migraña cronica o las tecnicas de neuromodulacion, obligan a introducir dentro de nuestras carteras de servicios la asistencia especializada en cefaleas. Aunque no disponemos de datos incontrovertibles, existen ya datos suficientes en la literatura que indican que esta atencion es eficiente en pacientes con cefaleas cronicas no solo en terminos de salud, sino tambien desde el punto de vista economico.

[Creation and enhancement of headache units: the view of neurologists and heads of neurology departments]. / Creacion y potenciacion de las unidades de cefalea: vision de los neurologos y jefes de servicio de neurologia.

Headache is the most common reason for visiting in neurology. Almost a third of all patients surveyed in this specialty visit for this reason. The gradual increase in the complexity of the care afforded to patients with headaches requires neurologists to become more specialised and leads to the creation of specialised units where this more complex care can be implemented. The heads of the neurology department are responsible for structuring and coordinating the different care units. This article shows the findings of a survey carried out on a group of heads of neurology departments in order to determine the current state of headache units, that is, their opinion regarding the creation, functioning and development of headache units in Spanish hospitals, and the parameters of their efficacy and effectiveness.

TITLE: Creacion y potenciacion de las unidades de cefalea: vision de los neurologos y jefes de servicio de neurologia.La cefalea constituye el motivo de consulta mas frecuente en neurologia. Casi la tercera parte de pacientes consultados en esta especialidad lo hace por este motivo. El gradual incremento en la complejidad de asistencia a pacientes con cefalea hace necesaria una mayor especializacion por parte de los neurologos y propicia la creacion de unidades especializadas donde desarrollar esta actividad asistencial mas compleja. La estructuracion y coordinacion de las distintas unidades asistenciales corresponde a los jefes de servicio de neurologia. En este articulo se recogen los resultados de una encuesta realizado a un grupo de jefes de servicio de neurologia para conocer el estado actual de las unidades de cefalea: su opinion sobre la creacion, funcion y desarrollo de unidades de cefalea en los hospitales españoles, y los parametros de eficacia y eficiencia de estas.

[Shaare Zedek Medical Center's model of an integrated division of internal medicine].

BACKGROUND: The specialty and practice of internal medicine have been subject to serious challenges in the last two decades. METHODS: We describe the integrative model of internal medicine as developed in our hospital, providing solutions to some major challenges. RESULTS: Major components include: (1) Senior physicians and residents are employed by the Division rather than individual Departments of Medicine, allowing for balanced distribution of professional capabilities. (2) Two medical departments specialize in geriatric medicine, while the other departments take care of younger, more intellectually challenging patients. Senior and junior staff members rotate through these departments, allowing for exposure to different patient populations and professional expertise. (3) The backbone of senior physicians is rewarded by a set of incentives, including dedicated time for research. (4) Senior staff from the subspecialties contributes annually 1-2 months as senior physicians in the departments and receive academic and other compensation for their efforts. (5) In cases where medical departments elsewhere are flooded with corridor admissions (a source of frustration and burnout), a short admission unit in the emergency department relieves internal medicine pressures and shortens evaluation and therapy for many patients. CONCLUSION: Our integrative model of internal medicine allows for improved patient and staff distribution, greater satisfaction among patients and family members, greater professional satisfaction among physicians, while resident vacancies are filled with competent residents.

[Dermatology day-care: between official rules and reality]. / Hôpital de jour de dermatologie : entre circulaire frontière et réalité

BACKGROUND: Official rules published in 2006 and 2010 concerning ambulatory care rates in France led to artificial redistribution of this activity from day-care hospitalization to consultations. In our dermatological day-care establishment, we compared the financial costs engendered for patients admitted for day-care hospitalization and those seen at consultations. PATIENTS AND METHODS: From 2011/01/10 to 2011/02/04, for each patient, we prospectively analyzed the following data: day-care hospitalization or consultation, age, sex, diagnosis, laboratory and radiological examination, non-dermatological consultations, time spent with the patient by doctors (interns, senior doctors) and nurses, with timing by a stop-watch. The hospital cost was the total for medical examinations (official nomenclature), non-dermatological consultations, physicians' and nurses' salaries and establishment overheads (216 €). The hospital revenue regarding the consultation group consisted of the sum of reimbursement for medical examination, dermatological and non-dermatological consultations, and regarding the day-care hospitalization group, the dermatology rate (670 €) or chemotherapy sessions (380 €). Results were compared using a Chi(2) test and a Student's t-test (P ≤ 0.05). RESULTS: One hundred and twenty-seven patients were included: 67 in the day-care hospitalization group and 60 in the consultation group. Patients in the day-care hospitalization group were older and had significantly more radiological examinations and non-dermatological consultations, but the number of laboratory examinations and skin biopsies did not differ between the two groups. The mean time spent by doctors was similar in both groups but the time spent by senior doctors without the help of interns was significantly greater and longer than the time for a standard consultation. Nurses spent a mean 72 minutes with each hospitalized patient and 35 minutes with consultation patients (P = 0.007). Hospital costs were identical in both groups at around 415 €. The hospital showed a profit for day-care hospitalization patients (252 €) and a loss (244 €) for consultation patients. DISCUSSION: Half of the patients studied were in day-care hospitalization and half were seen in consultations. The high number of bed-ridden patients with bullous pemphigoid accounts for the fact that day-care patients were older. The reasons for the significantly longer time spent by nurses with day-care hospitalized patients were administration and supervision of chemotherapy, skin care and nursing of bed-ridden patients. However, nurses spent 35 min with each consultation patient, justifying the need to maintain the posts of these staff in such day-care units. The availability of physicians for patients with severe dermatoses and the organization of medical examinations in the same place in the same day underscore the need for medical structures like day-care hospitalization. At present, time spent on intellectual work involving reflection is regrettably not taken into account, which is detrimental to this specialty. The hospital was in profit for day hospitalizations while consultations resulted in losses, in particular because of the absence of social security reimbursement of the establishment's overheads. CONCLUSION: Rules are in need of modification in order to allow the treatment of patients with more complicated conditions.

Republished: Daily consultant gastroenterologist ward rounds: reduced length of stay and improved inpatient mortality.

BACKGROUND: For gastroenterology, The Royal College of Physicians reiterates the common practice of two to three consultant ward rounds per week. The Royal Bolton Hospital NHS Foundation Trust operated a 26-bed gastroenterology ward, covered by two consultants at any one time. A traditional system of two ward rounds per consultant per week operated, but as is commonplace, discharges peaked on ward round days. OBJECTIVE: To determine whether daily consultant ward rounds would improve patient care, shorten length of stay and reduce inpatient mortality. METHODS: A new way of working was implemented in December 2009 with a single consultant taking responsibility for all ward inpatients. Freed from all other direct clinical care commitments for their 2 weeks of ward cover, they conducted ward rounds each morning. A multidisciplinary team (MDT) meeting followed immediately. The afternoon was allocated to gastroenterology referrals and reviewing patients on the medical admissions unit. RESULTS: The changes had an immediate and dramatic effect on average length of stay, which was reduced from 11.5 to 8.9 days. The number of patients treated over 12 months increased by 37% from 739 to 1010. Moreover, the number of deaths decreased from 88 to 62, a reduction in percentage mortality from 11.2% to 6%. However, these major quality outcomes involved a reduction in consultant-delivered outpatient and endoscopy activity. CONCLUSION: This new method of working has both advantages and disadvantages. However, it has had a major impact on inpatient care and provides a compelling case for consultant gastroenterology expansion in the UK.

Perceiving integration of a complementary medicine service within a general surgery department through documentation of consultations: a thematic analysis.

OBJECTIVE: This study aims to examine the meaning and practical implications of integration of a complementary medicine-based surgery service in a hospital setting (CISS--Complementary/Integrative Surgery Service) through analysis of consultation reports associated with this service. METHODS: Thematic analysis was used to evaluate CISS consultation reports in a hospital electronic consultant charting system during the first half year of the service's activity. RESULTS: 304 consultation reports were analyzed. Nurses initiated significantly more consultations than physicians (55% vs 7%). Consultation requests were gradually more focused on specific symptoms, possibly manifesting a better understanding of the scope of complementary medicine in the surgery setting. CISS practitioners responded in more biomedical language over time, albeit offering a more holistic perspective regarding patients' needs as well as clarifications regarding the nature of the treatment they provided. CONCLUSIONS: Diverse communication patterns in consultations evolved over time representing dynamics in multiple levels of integration of the CISS. PRACTICE IMPLICATIONS: Documented communication through consultations can provide a window to the process of integration of complementary medicine-based services in health systems.

[The implementation of risk management in a department of otolaryngology]. / Implementierung eines Risikomanagements in einer Hals-, Nasen-, Ohrenklinik.

The reasons for introducing risk management in hospitals are manifold. Not only legal but also ethical and moral aspects are of great importance.The implementation of risk management in a German department of otolaryngology is presented. Although various instruments were introduced, the main emphasis was placed on the establishment of a risk management team with the aim of prospectively and retrospectively addressing critical situations in hospital operation management and also with the goal of achieving a change of attitude towards mistakes, complications and damages in the clinic.Many aspects of the in-house processes were critically analyzed and optimization strategies were developed such as the introduction of checklists for preoperative patient identification. Furthermore the implemented CIRS has been well accepted.A meaningful objectivity of the results seems difficult. A main reason is that the index "reduction of damage and medical malpractice" is too small to make a conclusive statistical analysis. However, implementation of risk management is advisable for every ENT clinic.

[Implementation of a palliative care concept in a geriatric acute care hospital]. / Die Implementierung eines Palliativkonzepts in ein geriatrisches Akutkrankenhaus.

To integrate palliative care patients into an acute geriatric ward requires extensive and continuous education and preparation of all participating professionals. It can be a lengthy process to integrate palliative care concepts despite cooperation of the hospital administration. The group of patients to be integrated differs from the patients of regular geriatric wards because of a higher percentage of relatively young oncologic patients and they differ from a regular palliative ward because about 50% are non-oncologic patients, while the average age is much higher than in normal palliative care. It is possible to integrate specialized palliative care into a regular geriatric ward. Patients admitted without palliative intention will benefit the most from ward-integrated palliative care if the treatment aim turns this way. Ward-integrated palliative care can be an integral part of treating geriatric patients in addition to acute geriatric medicine, rehabilitation, and prevention. It can also provide caretakers and patients with the benefits from continuity of treatment and care.

A toolkit for incorporating genetics into mainstream medical services: Learning from service development pilots in England.

BACKGROUND: As advances in genetics are becoming increasingly relevant to mainstream healthcare, a major challenge is to ensure that these are integrated appropriately into mainstream medical services. In 2003, the Department of Health for England announced the availability of start-up funding for ten 'Mainstreaming Genetics' pilot services to develop models to achieve this. METHODS: Multiple methods were used to explore the pilots' experiences of incorporating genetics which might inform the development of new services in the future. A workshop with project staff, an email questionnaire, interviews and a thematic analysis of pilot final reports were carried out. RESULTS: Seven themes relating to the integration of genetics into mainstream medical services were identified: planning services to incorporate genetics; the involvement of genetics departments; the establishment of roles incorporating genetic activities; identifying and involving stakeholders; the challenges of working across specialty boundaries; working with multiple healthcare organisations; and the importance of cultural awareness of genetic conditions. Pilots found that the planning phase often included the need to raise awareness of genetic conditions and services and that early consideration of organisational issues such as clinic location was essential. The formal involvement of genetics departments was crucial to success; benefits included provision of clinical and educational support for staff in new roles. Recruitment and retention for new roles outside usual career pathways sometimes proved difficult. Differences in specialties' working practices and working with multiple healthcare organisations also brought challenges such as the 'genetic approach' of working with families, incompatible record systems and different approaches to health professionals' autonomous practice. 'Practice points' have been collated into a Toolkit which includes resources from the pilots, including job descriptions and clinical tools. These can be customised for reuse by other services. CONCLUSIONS: Healthcare services need to translate advances in genetics into benefits for patients. Consideration of the issues presented here when incorporating genetics into mainstream medical services will help ensure that new service developments build on the body of experience gained by the pilots, to provide high quality services for patients with or at risk of genetic conditions.

Collaborative care for alcohol-related liver disease.

By implementing collaborative care for patients with alcohol misuse and alcohol-related liver disease, the Royal Bolton Hospital aimed to improve and coordinate their care by recruiting a multidisciplinary team and placing the patient at the centre of all efforts. There has been a marked improvement in the accuracy of the drinking histories taken, detoxification, dietary documentation, and patient and staff attitudes and confidence, with enhanced satisfaction in patients, their families and staff and improved accessibility and communication. We observed a considerable increase in the number of inpatient and outpatient referrals and believe that it is more effective to work together in a joint gastroenterology/psychiatry team. There is a critical national need to establish steering groups of key clinical, managerial and commissioning personnel to address the growing problem of alcohol misuse. The appointment of dedicated alcohol health workers is central to this strategy.

[Rehabilitation integrated in acute medical treatment]. / Rehabilitering integrert i akuttbehandling av sykdom.

BACKGROUND: Rehabilitation integrated in acute medical treatment is of great importance to patients with acute cerebral stroke and to frail elderly people admitted to hospital with acute medical conditions or fractures. We will focus on the latter group, which receives the least attention, but steadily increases. METHODS: MEDLINE-search for relevant literature published during the last 15 years, and own clinical experience. RESULTS AND CONCLUSIONS: Results from randomized clinical studies indicate that early geriatric rehabilitation, integrated in the acute treatment of elderly frail patients with acute diseases or hip fractures, is more effective than treatment in general medical or orthopedic wards. Geriatric intervention does not seem to increase costs. The beneficial effects consist of reduced incidence, duration and severity of delirium; fewer iatrogenic complications, better functional capacity and in some studies reduced mortality without increasing the need for institutionalization. Prerequisites for success are adequate patient selection and dedicated geriatric and rehabilitation units with full treatment responsibility. Up to 2050, there will be a dramatic increase in the number of elderly in Norway. Restructuring and reorganization of medical and orthopedic hospital departments are some of the measures required to meet this challenge.

Early supported discharge for stroke patients improves clinical outcome. Does it also reduce use of health services and costs? One-year follow-up of a randomized controlled trial.

BACKGROUND: An early supported discharge service (ESD) appears to be a promising alternative to conventional care. The aim of this trial was to compare the use of health services and costs with traditional stroke care during a one-year follow-up. METHODS: Three hundred and twenty patients were randomly allocated either to ordinary stroke unit care or stroke unit care combined with ESD which was coordinated by a mobile team. The use of all health services was recorded prospectively; its costs were measured as service costs and represent a combination of calculated average costs and tariffs. Hospital expenses were measured as costs per inpatient day and adjusted for the DRG. RESULTS: There was a reduction in average number of inpatient days at 52 weeks in favour of the ESD group (p = 0.012), and a non-significant reduction in total mean service costs in the ESD group (EUR 18,937/EUR 21,824). ESD service seems to be most cost-effective for patients with a moderate stroke. CONCLUSION: Acute stroke unit care combined with an ESD programme may reduce the length of institutional stay without increasing the costs of outpatient rehabilitation compared with traditional stroke care.