The importance of simulation-based multi professional training in obstetric anesthesia: an update.

PURPOSE OF REVIEW: Simulation-based training remains an integral component of medical education by providing a well tolerated, controlled, and replicable environment for healthcare professionals to enhance their skills and improve patient outcomes. Simulation technology applied to obstetric anesthesiology continues to evolve as a valuable tool for the training and assessment of the multidisciplinary obstetric care team. RECENT FINDINGS: Simulation-based technology has continued to play a role in training and assessment, including recent work on interdisciplinary communication, recognition, and management of obstetric hemorrhage, and support in the low or strained resource setting. The COVID-19 pandemic has accelerated the evolution of simulation-based training away from a reliance on in-situ or high-fidelity manikin-based approaches toward an increasing utilization of modalities that allow for remote or asynchronous training. SUMMARY: The evolution of simulation for interdisciplinary training and assessment in obstetric anesthesia has accelerated, playing a greater role in aspects of communication, management of hemorrhage and supporting low or strained resource settings. Augmented reality, virtual reality and mixed reality have advanced dramatically, spurred on by the need for remote and asynchronous simulation-based training during the pandemic.

Organizace a cinnost multidisciplinárního týmu v onkologii / Organization and activity of a multidisciplinary team in oncology

Multidisciplinární péce je povazována za osvedcený postup pri plánování lécby a péci o pacienty s rakovinou. Je to integrovaný týmový prístup ke zdravotní péci, v nemz lékarstí a dalsí zdravotnictí pracovníci zvazují vsechny relevantní moznosti lécby a spolecne vypracovávají individuální plán lécby a péce o pacienta. Zahrnuje diskusi vsech príslusných zdravotnických pracovníku o moznostech a spolecné rozhodování o lécbe a plánech podpurné péce s prihlédnutím k osobním preferencím pacienta. Tento doporucený postup poskytuje rámec a soubor nástroju na podporu zavedení multidisciplinárních týmu v onkologii lokálne. Nenavrhuje univerzální prístup k multidisciplinárním onkologickým týmum, spíse rámcove navrhuje nekolik základních principu, které doplnuje o detailnejsí návod, jak multidisciplinární tým zavést, co je jeho náplní a jak jej udrzet. Mezi výhody multidisciplinárního prístupu k péci patrí: Pro pacienty: delsí prezití u pacientu, kterí jsou vedeni multidisciplinárním týmem; kratsí doba od stanovení diagnózy k zahájení lécby; vetsí pravdepodobnost, ze se jim dostane péce v souladu s klinickými doporucenými postupy, vcetne psychosociální podpory; lepsí prístup k informacím; vetsí spokojenost s lécbou a pécí. Pro zdravotnické pracovníky: lepsí péce o pacienty a výsledky díky vypracování dohodnutého lécebného plánu; zefektivnení lécebných postupu a snízení duplicity sluzeb; lepsí koordinace péce; vzdelávací prílezitosti pro zdravotnické pracovníky; zlepsení dusevní pohody zdravotnických pracovníku.

Multidisciplinary care is considered best practice in the treatment planning and care of cancer patients. It is an integrated team approach to healthcare in which doctors and other healthcare professionals consider all relevant treatment options and together develop an individualized treatment and care plan for the patient. It involves discussion by all relevant healthcare professionals about options and shared decision-making about treatment and supportive care plans, taking into account the patient's personal preferences. This guideline provides a framework and toolkit to support the implementation of multidisciplinary teams in oncology locally. It does not propose a universal approach to multidisciplinary oncology teams, rather, it proposes several basic principles as a framework, which it supplements with more detailed instructions on how to establish a multidisciplinary team, what its content is, and how to maintain it. Benefits of a multidisciplinary approach to care include: For patients: longer survival in patients who are managed by a multidisciplinary team; shorter time from diagnosis to initiation of treatment; more likely to receive care consistent with clinical guidelines, including psychosocial support; better access to information; greater satisfaction with treatment and care. For healthcare professionals: better patient care and outcomes through the development of an agreed treatment plan; streamlining treatment procedures and reducing duplication of services; better coordination of care; educational opportunities for healthcare professionals; improving the mental well-being of healthcare workers.

Teaming in the contemporary fertility clinic: creating a culture to optimize patient care.

When a diverse group of individuals is working together in the contemporary fertility clinic to provide time-sensitive and complex care for patients, a high degree of coordination and collaboration must take place. When performed dynamically, this process is referred to as teaming. Although the positive impact of teamwork in health care settings has been well established in the literature, the concept of teaming has limited foundation in the clinic. This review will provide an overview of how teaming can be used to improve patient care in today's fertility clinics. Approaches to integrating teaming into the clinic that will be discussed include framing, the creation of a psychologically safe environment for staff input, and facilitating collaborative constructs to support teaming. Best practices to implement teaming and how to address challenges to teaming in today's clinical environment will also be addressed.

Teaming in the ambulatory surgical space and crisis management strategies.

Outpatient procedures and flexible staffing models have become prevalent within the ambulatory surgical and procedural spaces of reproductive endocrinology and infertility practice. High volumes of outpatients are treated daily by rotating nurses, surgeons, and anesthesia staff, often with the added layer of trainees present. "Teaming" can allow stable units and ad hoc groups to partner better for enhanced efficiency, effectiveness, and patient experience in routine procedural activities. These skills then can be parlayed into the rare moments of crisis to improve safety outcomes. Teaming concepts, applied in routine and acute scenarios, can optimize clinical operations, patient experience, and outcomes in our reproductive endocrinology and infertility ambulatory procedural and surgical spaces.

Lessons learned from safe tracheostomy aftercare taskforce implemented during COVID-19 pandemic.

PURPOSE: At the height of the COVID-19 pandemic, our institution instituted a Safe Tracheostomy Aftercare Taskforce (STAT) team to care for the influx of patients undergoing tracheostomies. This review was undertaken to understand this team's impact on outcomes of tracheostomy care. METHODS: We compared retrospective data collected from patients undergoing tracheostomies at our institution from February to June 2019, prior to creation of the STAT team, to prospectively collected data from tracheostomies performed from February to June 2020, while the STAT team was in place and performed statistical analysis on outcomes of care such as decannulation prior to discharge, timely tube change, and post-discharge follow-up. RESULTS: We found that the STAT team significantly increased rate of decannulation prior to discharge (P < 0.0005), performance of timely trach tube change when indicated (P < 0.05), and rates of follow-up for tracheostomy patients after discharge from the hospital (P < 0.0005). CONCLUSION: The positive impact of the STAT team on outcomes of patient care such as decannulation prior to discharge, timely tube change, and post-discharge follow-up makes a strong case for its continuation even in non-pandemic times.

Non-alcoholic fatty liver disease in adults 2021: A clinical practice guideline of the Italian Association for the Study of the Liver (AISF), the Italian Society of Diabetology (SID) and the Italian Society of Obesity (SIO).

Nonalcoholic fatty liver disease (NAFLD) is a common and emerging liver disease in adults, paralleling the epidemic of obesity and diabetes, and leading to worrisome events (hepatocellular carcinoma and end-stage liver disease). In the last years, mounting evidence added insights about epidemiology, natural history, diagnosis and lifestyle-based or drug treatment of NAFLD. In this rapidly evolving scenario, members of the Associazione Italiana per lo Studio del Fegato (AISF), the Società Italiana di Diabetologia (SID) and the Società Italiana dell'Obesità (SIO) reviewed current knowledge on NAFLD. The quality of the published evidence is graded, and practical recommendations are made following the rules and the methodology suggested in Italy by the Centro Nazionale per l'Eccellenza delle cure (CNEC) and Istituto Superiore di Sanità (ISS). Whenever possible, recommendations are placed within the context the Italian Healthcare system, with reference to specific experience and local diagnostic and management resources. Level of evidence: Level of evidence of recommendations for each PICO question were reported according to available evidence.

The surgical debrief: Just another checklist or an instrument to drive cultural change?

INTRODUCTION: Post-procedural debrief is recommended to improve patient safety. We examined operating room (OR) clinicians' perceptions of the impact of a multi-disciplinary debrief on OR culture. METHODS: A survey was administered to 182 OR clinicians at a major academic medical center. Attitudes toward the surgical debrief and its effect on patient safety and OR culture were evaluated. RESULTS: Majority of clinicians (58.2%) believed creating a culture of safety in the OR was a shared care team responsibility, however, surgical attendings and trainees were more likely to assign this responsibility to the surgical attending. Few circulating nurses and trainees felt comfortable initiating a surgical debrief. Overall clinicians agreed that a debrief would impact both patient safety outcomes and OR culture. CONCLUSIONS: Clinicians felt implementation of a surgical debrief would positively affect the OR culture of safety by improving interdisciplinary communication and influencing the power hierarchy that exists in many ORs.

High and Sustained Participation in a Multi-year Voluntary Performance Measurement Initiative Among Primary Care Teams.

BACKGROUND: The province of Ontario, Canada has made major investments in interdisciplinary primary care teams. There is interest in both demonstrating and improving the quality of care they provide. Challenges include lack of consensus on the definition of quality and evidence that the process of measuring quality can be counter-productive to actually achieving it. This study describes how primary care teams in Ontario voluntarily measured quality at the team level. METHODS: Data for this 4-year observational study came from electronic medical records (EMRs), patient surveys and administrative reports. Descriptive statistics were calculated for individual measures (eg, access, preventive interventions) and composite indicators of quality and healthcare system costs. Repeated measures identified patient and practice characteristics related to quality and cost outcomes. RESULTS: Teams participated in an average of 5 of 8 possible iterations of the reporting process. There was variation between teams. For example, cervical cancer screening rates ranged from 21 to 86% of eligible patients. Rural teams had significantly better performance on some indicators (eg, continuity) and worse on others (eg, cancer screening). There were some statistical but small changes in performance over time. CONCLUSION: High, sustained voluntary participation suggests that the initiative served a need for the primary care teams involved. The absence of robust data standards suggests that these standards were not crucial to achieve participation. The constant level of performance might mean that measurement has not yet led to improvement or that measures used might not accurately reflect improvement. The data reinforce the need to consider differences between rural and urban settings. They also suggest that further analysis is needed to identify characteristics that teams can change to improve the quality of care their patients experience. The study describes a practical, sustainable real-world approach to performance measurement in primary care that was attractive to interdisciplinary teams.

Influence of endocrine multidisciplinary tumor board on patient management and treatment decision making.

BACKGROUND: Multidisciplinary Tumor Boards (MDT) are used to obtain input regarding cancer management. This study assessed the impact of our institutional Endocrine MDT. METHODS: MDT notes on patients with thyroid cancer treated during 2012-2018 were abstracted retrospectively from the electronic medical record. Management change (MC) was prospectively collected by the MDT coordinator. Biannual evaluations reviewed the impact of the MDT as observed by attendees. RESULTS: MC was recommended in 47 (15%) of 286 presentations, with additional imaging being the most frequent (43%). Presentation of recurrences were more likely to result in MC (24% vs. 13% initial, p = 0.03). Overall, 98% of attendees found the conference exceeded educational expectations. About 24% reported intending to use a more evidence/guideline-based approach after attending and this trend increased over time (p = 0.002). CONCLUSION: MDT presentations led to a higher rate of MC particularly in recurrent TC patients and increased evidenced-based practice for attendees.

Adaptation and validation of a Multidisciplinary Checklist for rounds in the Intensive Care Unit / Adaptación y validación de una Lista de Verificación Multidisciplinaria para rondas de visitas médicas en la Unidad de Cuidados Intensivos / Adaptação e validação de Checklist Multidisciplinar para rounds em Unidade de Terapia Intensiva

ABSTRACT Objective: to perform the adaptation, content validation and semantic analysis of a Multidisciplinary Checklist used in rounds in Intensive Care Units for adults. Method: a methodological study, consisting of three stages: Adaptation of the checklist, performed by one of the authors; Content validation, performed by seven judges/health professionals from a public teaching hospital in Paraná; and Semantic analysis, performed in a philanthropic hospital in the same state. Agreement of the judges and of the target audience in the content validation and semantic analysis stages was calculated using the Content Validity Index and the Agreement Index, respectively, with a minimum acceptable value of 0.80. Results: in the content validation stage, the checklist obtained a total agreement of 0.84. Of the 16 items included in the instrument, 11 (68.75%) were readjusted and four (25%) were excluded for not reaching the minimum agreement. The readjusted items referred to sedation; analgesia; nutrition; glycemic control; headboard elevation; gastric ulcer prophylaxis; prophylaxis for venous thromboembolism; indwelling urinary catheter, central venous catheter; protective mechanical ventilation and spontaneous breathing test. Regarding the items excluded, they referred to the cuff pressure of the orotracheal tube and to Nursing care measures such as taking the patient out of the bed, pressure injury prophylaxis, and ophthalmoprotection. In the semantic analysis, the final agreement of the instrument's items was 0.96. Conclusion: after two evaluation rounds by the judges, testing in critically-ill patients and high inter-evaluator agreement index, the Multidisciplinary Checklist is found with validated content suitable for use in rounds in intensive care.

RESUMEN Objetivo: realizar los procesos de adaptación, validación de contenido y análisis semántico de una Lista de Verificación Multidisciplinaria utilizada en rondas de visitas médicas en una Unidad de Cuidados Intensivos para adultos. Método: estudio metodológico, compuesto por tres etapas: Adaptación de la lista de verificación, realizada por una de las autoras; validación de contenido, a cargo de siete evaluadores/profesionales de la salud que trabajan en un hospital escuela público de Paraná; y análisis semántico, desarrollado en un hospital filantrópico del mismo estado. El nivel de concordancia entre los evaluadores y la población objetivo en las etapas de validación de contenido y análisis semántico se calculó por medio de Índice de Validez de Contenido y del Índice de Concordancia, respectivamente, con un valor mínimo aceptable de 0,80. Resultados: en la etapa de validación de contenido, la lista de verificación obtuvo un valor de concordancia total de 0,84. De los 16 ítems del instrumento, 11 (68,75%) fueron readaptados y cuatro (25%) fueron excluidos por no alcanzar el nivel mínimo de concordancia. Los ítems readaptados se referían a la sedación; analgesia; nutrición; control glicémico; elevación de la cabecera de la cama; profilaxis para úlcera gástrica; profilaxis para tromboembolia venosa; sonda vesical de demora, catéter venoso central; ventilación mecánica protectora y prueba de respiración espontánea. En relación a los ítems excluidos, se refirieron a la presión del manguito del tubo orotraqueal y a la atención de Enfermería, por ejemplo: retirar al paciente de la cama; profilaxis para úlceras por presión; y oftalmoprotección. En el análisis semántico, el nivel de concordancia final de los ítems del instrumento fue de 0,96. Conclusión: después de dos rondas de evaluación a cargo de especialistas, una prueba en pacientes y elevado índice de concordancia entre los evaluadores, la Lista de Verificación Multidisciplinaria se presenta como contenido validado y adecuado para ser empleado en rondas de visitas médicas en cuidados intensivos.

RESUMO Objetivo: realizar a adaptação, validação de conteúdo e análise semântica de um Checklist Multidisciplinar utilizado em rounds em Unidade de Terapia Intensiva Adulto. Método: estudo metodológico, composto de três etapas: Adaptação do checklist, realizada por uma das autoras; validação de conteúdo, realizado por sete juízes/profissionais de saúde de um hospital de ensino público do Paraná; e análise semântica, realizado em um hospital filantrópico do mesmo estado. A concordância dos juízes e do público-alvo nas etapas validação de conteúdo e análise semântica foi calculada pelo índice de validade de conteúdo e índice de concordância, respectivamente, com valor mínimo aceitável de 0,80. Resultados: na etapa validação de conteúdo, o checklist obteve concordância total de 0,84. Dos 16 itens do instrumento, 11 (68,75%) foram readequados e quatro (25%) foram excluídos por não alcançarem a concordância mínima. Os itens readequados se referiam à sedação; analgesia; nutrição; controle glicêmico; elevação da cabeceira; profilaxia para úlcera gástrica; profilaxia para tromboembolismo venoso; sonda vesical de demora, cateter venoso central; ventilação mecânica protetora e teste de respiração espontânea. Já em relação aos itens excluídos, estes se referiam à pressão do balonete do tubo orotraqueal e cuidados de enfermagem, como: retirada do paciente do leito; profilaxia para lesão por pressão; e oftalmoproteção. Na análise semântica, a concordância final dos itens do instrumento foi 0,96. Conclusão: o Checklist Multidisciplinar após duas rodadas de avaliação por juízes, teste em pacientes críticos e alto índice de concordância interavaliadores se apresenta com conteúdo validado e adequado para uso em rounds na assistência intensiva.

Multidisciplinary management to optimize outcome of ultrasound-guided high-intensity focused ultrasound (HIFU) in patients with uterine fibroids.

Little is known about the specific anaesthesiological and multidisciplinary management of high-intensity focused ultrasound (HIFU) in uterine fibroids. This observational single-center study is the first reporting on an interdisciplinary approach to optimize outcome following ultrasound (US)-guided HIFU in German-speaking countries. A sample of forty patients with symptomatic uterine fibroids was treated by HIFU. Relevant treatment parameters such as total treatment time for intervention, anaesthesia, and sonication time as well as total energy, body temperature, peri-interventional medication and complications were analyzed. Interventional variables did not correlate significantly either with opioid dose or with body temperature. The average fibroid volume reduction rate was 37.8% ± 23.5%, 48.5% ± 22.0% and 70.2% ± 25.5% after 3, 6 and 12 months, respectively. No major anaesthesiological complications occurred apart from an epileptic seizure prior to HIFU treatment in one patient. Peri-procedural hyperthermia (> 37.5 °C) occurred in two patients. Post-procedural two patients experienced a sciatic nerve irritation up to one year; one patient with very large treated fibroid experienced strong short-lasting post-procedural pain. There were two complication-free pregnancies of HIFU-treated patients. Multidisciplinary management is crucial to optimize safety and outcome of US-guided HIFU for uterine fibroids. Peri-procedural pain and temperature management are critical points where an adequate collaboration between anesthesiologist and interventionalist is mandatory.

Effect of a Multidisciplinary Pulmonary Embolism Response Team on Patient Mortality.

Multidisciplinary Pulmonary Embolism Response Teams (PERTs) may improve the care of patients with a high risk of pulmonary embolism (PE). The impact of a PERT on long-term mortality has never been evaluated. An observational analysis was conducted of 137 patients before PERT implementation (between 2014 and 2015) and 231 patients after PERT implementation (between 2016 and 2019), presenting to the emergency department of an academic medical center with submassive and massive PE. The primary outcome was 6-month mortality, evaluated by univariate and multivariate analyses. PERT was associated with a sustained reduction in mortality through 6 months (6-month mortality rates of 14% post-PERT vs 24% pre-PERT, unadjusted hazard ratio of 0.57, Relative Risk Reduction of 43%, p = 0.025). There was a reduced length of stay following PERT implementation (9.1 vs 6.5 days, p = 0.007). Time from triage to a diagnosis of PE was independently predictive of mortality, and the risk of mortality was reduced by 5% for each hour earlier that the diagnosis was made. In conclusion, this study is the first to demonstrate an association between PERT implementation and a sustained reduction in 6-month mortality for patients with high-risk PE.

Maternal and Fetal Outcomes in Women with Diabetes in Pregnancy Treated before and after the Introduction of a Standardized Multidisciplinary Management Protocol.

BACKGROUND: Diabetes in pregnancy is associated with an increased risk to the woman and to the developing fetus. Currently, there is no consensus on the optimal management strategies for the follow-up and the timing of delivery of pregnancies affected by gestational and pregestational diabetes, with different international guidelines suggesting different management options. MATERIALS AND METHODS: We conducted a retrospective cohort study from January 2017 to January 2021, to compare maternal and neonatal outcomes of pregnancies complicated by gestational and pregestational diabetes, followed-up and delivered in a third level referral center before and after the introduction of a standardized multidisciplinary management protocol including diagnostic, screening, and management criteria. RESULTS: Of the 131 women included, 55 were managed before the introduction of the multidisciplinary management protocol and included in group 1 (preprotocol), while 76 were managed according to the newly introduced multidisciplinary protocol and included in group 2 (after protocol). We observed an increase in the rates of vaginal delivery, rising from 32.7% to 64.5% (<0.001), and the rate of successful induction of labor improved from 28.6% to 86.2% (P < 0.001). No differences were found in neonatal outcomes, and the only significant difference was demonstrated for the rates of fetal macrosomia (20% versus 5.3%, P: 0.012). Therefore, the improvements observed in the maternal outcomes did not impact negatively on fetal and neonatal outcomes. CONCLUSION: The introduction of a standardized multidisciplinary management protocol led to an improvement in the rates of vaginal delivery and in the rate of successful induction of labor in our center. A strong cooperation between obstetricians, diabetologists, and neonatologists is crucial to obtain a successful outcome in women with diabetes in pregnancy.

Multidisciplinary aerodigestive program at a children's hospital: A protocol for a prospective observational study.

BACKGROUND: Children with complex chronic multisystemic diseases frequently require care from multiple pediatric subspecialists. The aerodigestive program is a multidisciplinary program that diagnoses and treats pediatric patients with complex multi-systematic problems affecting airway, breathing, feeding, swallowing, or growth. The aim of this study is to present the protocol of the aerodigestive program of a children's hospital. METHODS AND DESIGN: This study is a prospective study to evaluate and compare the overall improvement of patients' objective and subjective conditions before and after the AeroDigestive Team (ADT) program. Among children from 1 month to 18 years of age, patients with complex problems of the airway, breathing, feeding, swallowing, or growth meeting at least two parameters of the inclusion criteria were enrolled. The overall process included referral based on the inclusion criteria, enrollment of ADT program with informed consents, interview and questionnaire for assessing patients' medical condition, prescheduling appointment, multi-specialists' evaluation, monthly team meetings, wrap-up discussion with the patients and family, therapeutic intervention, and follow-up at 6 months with the assessment of outcome measures. The outcome was evaluated objectively and subjectively. The objective outcome measure was divided into surgical or medical intervention, assessment of changes in medical condition, and follow-up study. Both caregiver interviews and questionnaires using a scoring system were used as subjective outcome measures before and after the ADT program. Children were scheduled to be followed-up at 6 months after the interventions or ADT meeting. DISCUSSION: The aerodigestive program is expected to provide comprehensive and multidisciplinary management of children with complex airway and digestive tract disorders.

Optimizing Situation Awareness to Reduce Emergency Transfers in Hospitalized Children.

BACKGROUND AND OBJECTIVES: Interventions to improve care team situation awareness (SA) are associated with reduced rates of unrecognized clinical deterioration in hospitalized children. By addressing themes from recent safety events and emerging corruptors to SA in our system, we aimed to decrease emergency transfers (ETs) to the ICU by 50% over 10 months. METHODS: An interdisciplinary team of physicians, nurses, respiratory therapists, and families convened to improve the original SA model for clinical deterioration and address communication inadequacies and evolving technology in our inpatient system. The key drivers included the establishment of a shared mental model, psychologically safe escalation, and efficient and effective SA tools. Novel interventions including the intentional inclusion of families and the interdisciplinary team in huddles, a mental model checklist, door signage, and an electronic health record SA navigator were evaluated via a time series analysis. Sequential inpatient-wide testing of the model allowed for iteration and consensus building across care teams and families. The primary outcome measure was ETs, defined as any ICU transfer in which the patient receives intubation, inotropes, or ≥3 fluid boluses within 1 hour. RESULTS: The rate of ETs per 10 000 patient-days decreased from 1.34 to 0.41 during the study period. This coincided with special cause improvement in process measures, including risk recognition before medical response team activation and the use of tools to facilitate shared SA. CONCLUSIONS: An innovative, proactive, and reliable process to predict, prevent, and respond to clinical deterioration was associated with a nearly 70% reduction in ETs.