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PubMedDate not supplied

Implementing a multidisciplinary HIV diarrhea critical pathway in the acute care setting.

Clinical pathways are the new strategy for managing hospital length of stay and cost in the changing, dollar-driven arena of health care. For patients with AIDS, HIV-related diarrhea is a potential source of increased morbidity that results in increased hospitalization and health care costs. This article describes the development and implementation of a multidisciplinary HIV Diarrhea Critical Pathway at Mount Sinai Medical Center of Greater Miami in South Florida. The focus of this article is on the nursing issues that arose during the piloting of the Diarrhea Critical Pathway and on the "how-tos" of its use. Initial evaluation of the first 3 years of using the diarrhea pathway is reported.

Cost Control↗

PubMed2002

A multidisciplinary team approach to reducing medication variance.

BACKGROUND: In March 2000 a multidisciplinary team was formed at Williamsburg Community Hospital (Williamsburg, Virginia) to address medication-related patient safety initiatives. MEDICATION SAFETY TEAM: The team focused on promoting a nonpunitive reporting environment, developing a collaborative medication administration policy, and designing an education and communication plan that promoted safe medication practices. In creating a nonpunitive environment, the first step was to revise the medication variance reporting policy. The team focused on process improvement and removed all references to corrective action from the policy. It launched an extensive educational effort throughout the hospital to raise awareness of the change in policy and to increase the focus on patient safety initiatives. The team also oversaw development of a comprehensive medication administration policy, which consolidated nursing, physician, and pharmacy practices. The team implemented a number of quick fixes that generated momentum and provided some immediate successes. RESULTS: Within a 9-month period (May 2001-January 2002), the number of reports doubled. As the number of variance reports increased, a subcommittee formed, with the specific responsibility of reviewing the reports on a weekly basis. DISCUSSION: The team sought to change the environment and attitudes related to medication variances and reporting. This was an organization wide change that required employees to change their perceptions regarding the purpose of reporting. Implementing the changes in small bites to realize immediate successes helped provide the impetus to keep the team focused and energized in tackling this huge endeavor. The team provided the ability to solve problems and recommend changes quickly and effectively from a variety of perspectives.

Attitude of Health Personnel↗

PubMed1997

The development and implementation of an integrated multidisciplinary clinical pathway.

Clinical pathways, linear time-related representations of patient care processes, are widely encouraged as a mechanism to outline efficient, cost-effective, multidisciplinary care. The translation of pathways from concept to reality is, however, predictably difficult. All caregivers are dedicated to a common goal, but organizational, personal, and professional perspectives are barriers to development of a common tool. Moreover, the building process requires the discovery, articulation, and communication of previously tacit patient care processes. Although no prescription can work for all pathway development, some strategies can help ensure the best possible chance of pathway success. Participants must recognize that between-patient variability can be expected to decrease with pathway implementation, and educational processes must support that aim. "Stakeholder groups" must be identified and their investment must be assessed, with careful attention paid to acquiring the unconditional support of institutional leadership. Planning of precise building, implementation, and piloting processes, with provision for facilitation of building and implementation processes, is critical. Those charged with pathway development must commit to the establishment and explication of clear goals (economic and quality outcomes) and to careful integration of the pathway with planned and existing continuous quality improvement processes. These strategies are illustrated with actual experiences in implementing cystectomy and pressure ulcer pathways in one academic medical center.

Communication↗

PubMed2002

Multidisciplinary management of breast cancer concurrent with pregnancy.

The management of PABC is very difficult. The incidence of PABC is low, but may be increasing because of the number of women who are becoming pregnant at a later age. More investigation is needed to understand whether the biology of PABC is different from that of breast cancer in nonpregnant women. One exciting area of further research is the potential relationship between mutations in known breast cancer susceptibility genes and breast cancer development during pregnancy. Diagnosis or PABC remains challenging because of the anatomic and physiologic changes that occur in the breast during pregnancy. Understanding the generic influences on PABC may help physicians in diagnosing this disease earlier, and understanding the tumor-receptor characteristics of PABC can help physicians deliver effective treatment. The various modalities available for treatment of PABC and their risks and benefits must be discussed openly with patients and their families. Abortion is not usually recommended. Modified radical mastectomy is the recommended treatment for PABC diagnosed during the first trimester. Neoadjuvant or adjuvant chemotherapy can be given with minimal risks to the fetus during the second or third trimester. Radiation therapy is contraindicated during pregnancy because of the potential for injury to the fetus. Breast conservation therapy, with radiation treatments given after delivery or after neoadjuvant chemotherapy, is an option for women with PABC diagnosed late in pregnancy. Once the appropriate treatment modality is chosen, its implementation must not be delayed because of the pregnancy. Most of the literature shows that women with PABC have the same survival stage for stage as nonpregnant women with breast cancer. But some studies suggest that the prognosis is worse for patients who present with advanced-stage PABC. Finally, recurrence and survival in most patients previously treated for breast cancer do not appear to be adversely affected by subsequent pregnancy. Above all, the patient with breast cancer diagnosed during pregnancy is best served by early and continued involvement of a multidisciplinary cancer treatment team.

Adult↗

PubMed1999

Multidisciplinary team renal rehabilitation: interventions and outcomes.

Multidisciplinary team renal rehabilitation produces positive patient outcomes by broadening the knowledge base and evening out the work load. Rehabilitation is no longer viewed as an extra program to patient care done by a few people but seen as an integral part of the patients' care and dialysis treatment. Focusing on the 5E's of renal rehabilitation developed by the Life Options Rehabilitation Advisory Council, Renal Care Group of the Midwest, Inc has achieved positive clinical patient outcomes, such as meeting dialysis adequacy benchmark goals. Interventions and outcomes of two of the 5E's, education and exercise, are discussed.

Exercise Therapy↗

PubMedDate not supplied

Jacksonville Pediatric Injury Control System: a multidisciplinary quality improvement program.

The Jacksonville Pediatric Injury Control System is a multidisciplinary forum created to identify, discuss, and recommend actions that improve the care of pediatric trauma patients in the Jacksonville, Florida, area. Daily events that affect the outcome of injured children are measured. Outcome can no longer be measured by merely decreasing mortality and patient impairment but must also include how efficiently this is achieved. To improve our ability to treat pediatric injury, factors that undermine this efficiency must be controlled. The Jacksonville Pediatric Injury Control System accomplishes this in a manner that uses existing resources to focus the pursuit of excellence for an entire community of professionals committed to improved care for the injured child.

Adolescent↗

PubMed1997

Young Moms' Clinic: a multidisciplinary approach to pregnancy education in teens and in young single women.

STUDY OBJECTIVE: To study outcome of pregnant adolescents and single young women who attended and those who chose not to attend a nonurban, developmentally appropriate, pilot antenatal clinic called the "Young Moms' Clinic." To study "perceived" outcome among the Young Moms' Clinic participants. METHODS: A multidisciplinary clinic was established to provide education about pregnancy, childbirth, infant care, contraception, and healthy lifestyles to young mothers with similar backgrounds. Over a 2-year period, all adolescents and single young mothers aged 13-23 years were invited to attend the Young Moms' Clinic after the first trimester. The Clinic group consisted of the first 101 young women who were invited and chose to attend. The nonclinic group consisted of the first 95 young women who were invited but declined to attend. Both groups had the same obstetric care givers, had a similar number of prenatal visits (median number, 12), and delivered in the same hospital. Univariate and multivariate analyses were performed to determine whether participation in the clinic was an independent factor in outcome. RESULTS: Maternal weight gain and infant birth weight were significantly higher in the Clinic group. Pregnancy complications (preterm labor, intrauterine growth retardation, anemia) were significantly higher in the nonclinic group. Participants in the nonclinic group were almost three times as likely to have cesarean section delivery as those in the Clinic group. Neonatal intensive care unit transfer occurred only in infants of the control group. CONCLUSIONS: Participation of pregnant adolescent and young adult women from a nonurban community in a developmentally targeted pilot, prenatal program resulted in fewer pregnancy complications and improved outcome in comparison with those who chose not to participate in the program. The results may be subject to bias because of self-selection among participants.

Adolescent↗

PubMed1996

Conscious sedation: a multidisciplinary team approach.

The administration of intravenous conscious sedation for patients undergoing minor procedures has increased in many settings throughout health care. Recognizing this, managers are challenged to develop policies to standardize the quality of patient care delivery. Consumer interest and knowledge in health care has increased dramatically in the last few years. Their demands for decreased cost, increased technology, and quality of care have compelled health care organizations to adopt quality management models. Quality improvement teams were developed to look at processes crossing departmental boundaries. Teams facilitate dialogue, understanding, and knowledge, and use the scientific method to design, streamline, and improve processes. The authors share strategies for policy development using a 7-step quality improvement process with a multidisciplinary team approach.

Clinical Competence↗

PubMed1997

Multidisciplinary rehabilitation for chronic back pain in an outpatient setting: a controlled randomized trial.

Based on existing models for pain chronicity and effective treatment strategies for patients with chronic low back pain, a multidisciplinary rehabilitation programme for an outpatient group setting was developed. The main treatment components address the patient's physical functional capacity (functional restoring), cognitive and affective processes (pain management strategies), and behavioural and ergonomical aspects (back school elements). Short-term (immediately after intervention) and long-term effects (at 6-months follow-up) of the intervention were assessed in a randomized controlled study. Dependent variables were pain measures, functional capacity, disability, muscular strength and endurance, pain and posture-related self-efficacy, attitudes, depression, well-being, behavioural habits and posture assessed by a standardized behavioural observation method. Immediately after the intervention, patients in the treatment group (n=36) showed significant improvement over patients in the control group (n=29) in all variables except depression and muscular strength and endurance. At 6-months follow-up, compared to pretreatment scores, patients continued to show beneficial effects in pain intensity and frequency, posture, posture-related self-efficacy and well-being. In contrast to post-treatment results, there were also significant improvements in strength and endurance. Overall results testify to the effectiveness of the intervention programme. Future studies (with larger sample sizes) should aim at a further improvement of functional capacity and disability perception, an analysis of differential treatment effects, and strategies for an improved long-term maintenance of the changes induced by the programme.

Clinical Trial↗

PubMed2002

Detecting early clinical deterioration in chronic heart failure patients post-acute hospitalisation-a critical component of multidisciplinary, home-based intervention?

AIMS: To firstly describe the prevalence, characteristics and consequences of early clinical deterioration (ECD) in chronic heart failure (CHF) patients discharged from acute hospital care and, secondly, to examine the potential benefits of a multidisciplinary, home-based intervention (HBI) in limiting the common sequelae of such deterioration. METHODS: This phenomenon was studied in 90 CHF patients assigned to the intervention arm of a randomised study of HBI. ECD was defined as death, unplanned re-admission or clinical instability (detected at a home visit) within 14 days of hospital discharge. Multivariate analysis was used to determine the independent correlates of ECD. Using these data, a 1:1 case-control ratio of patients assigned to the usual care arm of the study was selected to match those patients exhibiting non-fatal ECD and subject to HBI. Subsequent morbidity and mortality rates were then compared on the basis of the presence or absence of non-fatal ECD and/or HBI. RESULTS: Of the 90 patients assigned to HBI, two died suddenly, five required an unplanned re-admission to hospital and 28 were found to be clinically unstable at a planned home visit, within 14 days of discharge from the index admission. The combined prevalence of ECD this cohort was therefore 39% (35 of 90 patients) and was independently correlated with greater age (OR=1.1 per yearly increment; P<0.001) and comorbidity (OR=2.0 per incremental Charlson index of comorbidity score; P<0.001). Patients who exhibited clinical instability at the home visit were significantly more likely to be non-adherent to prescribed treatment (10 of 28 vs. 9 of 55; P<0.05). Compared to the remainder of the cohort also subject to HBI, despite remedial intervention, patients who exhibited non-fatal ECD had reduced event-free survival (11 of 33 vs. 38 of 55; P<0.001), more frequent unplanned re-admission (0.2 vs. 0.1 admissions/patient/month; P<0.01), and more prolonged hospital stay (1.6 vs. 0.5 days/patient/month; P<0.001) in the subsequent 6-month period. However, compared to case-controls, these patients (n=33 in both groups) had fewer days of hospitalisation (1.6 vs. 3.6 days/patient/month; P=0.05) and, most significantly, were more likely to survive to 6 months (6 vs. 13 died; P<0.05). CONCLUSION: ECD is a common phenomenon in older CHF patients discharged from acute hospital care and is associated with poorer health outcomes in the longer-term. Post-discharge HBI is an important means for identifying and addressing ECD. Although HBI conveys benefits incremental to usual care, these data also provide a sound basis for increasing its effectiveness by applying earlier home visits in selected 'high-risk' patients.

Acute Disease↗

PubMed2003

Is multidisciplinary care of heart failure cost-beneficial when combined with optimal medical care?

BACKGROUND: Multidisciplinary care (MDC) of heart failure (HF) can significantly reduce rates of unplanned hospitalisation, the major cost component of HF care. AIMS: This prospective, randomised, controlled study examines the cost-benefits of MDC of HF in the setting of optimal medical care. METHODS: 98 NYHA class IV HF patients (mean age 70.8+/-10.5 years) were randomised to MDC (n=51) or routine care (RC; n=47) of HF. A direct intervention cost was calculated from contact time (scheduled and unscheduled) spent by the MDC team. Unplanned hospitalisation costs for HF were calculated at a daily rate of 242. Outcomes were determined in monetary terms, i.e. the cost of the service per hospitalisation prevented and net costs/savings at 3 months. RESULTS: The direct intervention cost of the MDC team was 5860, with an average cost per patient of 113 (95% Cl: 97-128). At 3 months, there were a total of 12 unplanned HF readmissions in the RC group (25.5% rate, 195 days) compared to 2 in the MDC group (3.9% rate, 17 days). The number needed to treat to prevent one hospitalisation for HF was 6 over 3 months. The cost of the service per hospitalisation prevented was 586. The intervention produced a net cost saving of 37,216 for 51 patients treated over 3 months. Sensitivity analyses using 50% variation in costs and lower relative risk reductions confirmed the cost-benefits of the intervention. CONCLUSION: MDC of HF remains cost-beneficial when combined with optimal, medical care. The significant clinical and cost-benefits suggest that this intensive approach to MDC and medical management should become the standard of care for HF.

Aged↗

PubMed2006

Multidisciplinary teams in cancer care: are they effective in the UK?

Cancer care can be complex, and given the wide range and numbers of health-care professionals involved, an enormous potential for poor coordination and miscommunication exists. Multidisciplinary teams (MDTs) should improve coordination, communication, and decision making between health-care team members and patients, and hopefully produce more positive outcomes. This review describes the many practical barriers to the successful implementation of MDT working, and shows that despite an increase in the delivery of cancer services via this method, research showing the effectiveness of MDT working is scarce.

Communication Barriers↗

PubMed2006

Multidisciplinary care in oncology: medicolegal implications of group decisions.

Consensus is growing that multidisciplinary meetings (MDMs) provide the best means of formulating comprehensive treatment plans for patients with cancer. Although many doctors attend MDMs and contribute to the decision-making process, only a few will become involved in a patient's care after the team meeting. Despite this, if a patient was grieved by a decision made in a MDM and wished to recover damages, all doctors present at the meeting would be personally accountable for decisions related to their area of expertise. Doctors should be made aware of the legal implications of their participation in such meetings. A greater awareness of these responsibilities and improved team dynamics should optimise outcomes for patients while limiting exposure of the participants to legal liability. Special attention should be given to providing patients with adequate information in this combined speciality setting.

Humans↗

PubMed2002

Work site, physician's office, or medical university clinic: the effect of setting on success in a multidisciplinary weight-loss program.

The effect of treatment setting on success in a 16-week multidisciplinary cognitive-behavioral weight-management program was examined. Twenty-seven women and six men with an average initial weight of 198.13 lb (+/-39.10) participated in the program at a medical university (MU), their primary care physician's office (PCP), or their work site (WS). The average amount of weight lost, body mass index (BMI) decrement, and number of sessions attended were compared as measures of success between programs. Results supported the hypothesis that treatment setting affects program success [F(6,40)=0.54, P<.05]. WS was more effective than PCP [Wilk's lambda=0.59, P<.05] in promoting weight loss [F(1,2)=5.22, P<.05]. Results indicate that the ongoing contingencies in the WS environment promote weight loss through more consistent adherence to suggested weight-loss strategies.

Journal Article↗

PubMed2003

Findings from a multidisciplinary clinical case series of females with Rett syndrome.

Systematic data from a multidisciplinary clinical assessment of a large series of females with Rett syndrome (RS; n=87) is presented. Participants' ages ranged from 2 years 1 month to 44 years 10 months. Areas assessed included oromotor skills, feeding problems, growth, breathing abnormalities, mobility, postural abnormalities and joint deformities, epilepsy, hand use and stereotypies, self-care, and cognitive and communication skills. Many previously reported trends in the presentation of RS over time were confirmed, notably the increasingly poor growth and near pervasiveness of fixed joint deformities and scoliosis in adulthood. In contrast, there was a slight trend towards improved autonomic function in adulthood, whereas feeding difficulties increased into middle childhood and then reached a plateau. Improvements in mobility into adolescence were followed by a decline in those skills in adulthood. Levels of dependency were high, confirming findings from previous studies. Despite the presence of repetitive hand movements, a range of hand-use skills was seen in individuals of all ages. Cognitive and communication skills were limited, but there was little evidence of deterioration of these abilities with age. These findings confirm that RS is not a degenerative condition and indicate that intervention and support to maintain and increase motor skills, daily living skills, and cognitive and communicative functioning are appropriate targets for individuals with RS.

Activities of Daily Living↗

PubMed1995

Multidisciplinary management of dysphagia: the first 100 cases.

A report of the first 100 patients treated in the multidisciplinary Dysphagia Clinic in Salisbury District Hospital is presented. It was established in January 1992 and involves the Departments of ENT Surgery, Clinical Radiology and Speech and Language Therapy. In the first 18 months, 100 patients have been assessed and treated. These included 46 males and 54 females, between the ages of four and 93 years. Neurological problems accounted for 39 cases. The management comprised the assessment clinic, videofluoroscopy in 83 patients, and finally the appropriate treatment. Forty-four patients were treated primarily by swallowing therapy. Seventy-three patients showed complete recovery, resolution of their symptoms or did not require treatment. Two patients were still under treatment at the time of writing this paper.

Adolescent↗

PubMed2006

The Bradford bone-anchored hearing aid programme: impact of the multidisciplinary team.

OBJECTIVES: The aim of this study was to assess the impact on implant survival, abutment skin reaction and patient satisfaction in patients implanted with a bone-anchored hearing aid (BAHA), following the introduction of a multidisciplinary team (MDT) in 1997. DESIGN AND METHODS: Part prospective and retrospective analysis. Implant survival and cause of failures were recorded along with abutment skin reaction (graded as none, mild, moderate and severe, according to the amount of wound care required). Patient satisfaction and quality of life were assessed using a questionnaire enquiring about several aspects of the use and benefits of their BAHA. SETTING AND PARTICIPANTS: Eighty patients treated at the Bradford Royal Infirmary between 1991 and 2005. The unit is a recognized tertiary referral centre. RESULTS AND CONCLUSIONS: Twelve out of 80 implants failed, giving an overall failure rate of 15 per cent. Kaplan-Meier survival curves show a steady decrease in implant survival. The MDT had a positive effect on implant survival and adverse skin reactions, with a higher proportion of patients experiencing no reaction after its introduction. There was a 92.5 per cent response rate to the questionnaire. Overall patient satisfaction was high, both before and after the introduction of the MDT.

Adolescent↗

PubMed1999

Lexical entries and rules of language: a multidisciplinary study of German inflection.

Following much work in linguistic theory, it is hypothesized that the language faculty has a modular structure and consists of two basic components, a lexicon of (structured) entries and a computational system of combinatorial operations to form larger linguistic expressions from lexical entries. This target article provides evidence for the dual nature of the language faculty by describing recent results of a multidisciplinary investigation of German inflection. We have examined: (1) its linguistic representation, focussing on noun plurals and verb inflection (participles), (2) processes involved in the way adults produce and comprehend inflected words, (3) brain potentials generated during the processing of inflected words, and (4) the way children acquire and use inflection. It will be shown that the evidence from all these sources converges and supports the distinction between lexical entries and combinatorial operations. Our experimental results indicate that adults have access to two distinct processing routes, one accessing (irregularly) inflected entries from the mental lexicon and another involving morphological decomposition of (regularly) inflected words into stem + affix representations. These two processing routes correspond to the dual structure of the linguistic system. Results from event-related potentials confirm this linguistic distinction at the level of brain structures. In children's language, we have also found these two processes to be clearly dissociated; regular and irregular inflection are used under different circumstances, and the constraints under which children apply them are identical to those of the adult linguistic system. Our findings will be explained in terms of a linguistic model that maintains the distinction between the lexicon and the computational system but replaces the traditional view of the lexicon as a simple list of idiosyncrasies with the notion of internally structured lexical representations.

Adult↗