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Yi-Hung Lai,1,2 Ming-Ju Wu,3 Hsin-Hua Chen,4,5 Shih-Ping Lin,4,6 Chun-Yi Wu,3,4 Chun-Shih Chin,4,7 Cheng-Hsien Lin,4,8 Sz-Iuan Shiu,4,9 Ying-Cheng Lin,4,9 Hui-Chi Chen,1 Shu-Chin Hou,1 Ching-Wein Chang1 1Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan; 2Department of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan; 3Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 4Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 5Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 6Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 7Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 8Division of Hematology and Oncology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 9Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, TaiwanCorrespondence: Ching-Wein Chang, Department of Nursing, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan, Email wen6081@gmail.comObjective: A huddle is a short, regular meetings to discuss existing or emerging patient safety issues. Hospital administrators can encourage healthcare staff to voluntarily examine the potential occurrence and severity of risks, thereby enhancing awareness of patient safety. The purpose of this study is to explore the effects of huddle intervention on patient safety culture among medical team members and related factors.Methods: We used a one-group pretest-posttest research design and convenience sampled 109 members of the general internal medicine ward team members from a medical center in central Taiwan. They participated 2 times per week in 15-min huddles from 08:15 to 08:30 in the morning, which lasted for a total of 4 weeks. The process was based on submitted ideas, approved ideas, research ideas and standardization, and data on the safety attitudes questionnaire (SAQ) were collected during the huddles’ intervention pretest and posttest.Results: After the huddle intervention, we found significantly improved scores for safety attitude, teamwork climate (76.49± 16.13 vs 83.26± 13.39, p < 0.001), safety climate (75.07± 16.07 vs 82.63± 13.72, p < 0.001), job satisfaction (73.67± 19.84 vs 83.39± 17.21, p < 0.001), perceptions of management (77.87± 19.99 vs 84.86± 16.03, p < 0.001) and working conditions (78.96± 18.16 vs 86.18± 14.90, p < 0.001). Correlation analyses on the differences between pretest and posttest showed that age had a significant correlation with safety climate (r = 0.22, p = 0.022) and working conditions (r = 0.20, p = 0.035). The number of times to participate in a huddle had a significant correlation with teamwork climate (r = 0.33, p =< .001), safety climate (r = 0.30, p = 0.002), job satisfaction (r = 0.19, p = 0.043), and work conditions (r = 0.28, p = 0.003).Conclusion: Huddles improve clinical team members’ understanding of different dimensions and relate factors of safety attitudes. Implementation of the huddles involved standardized process will help hospital administrators understand the steps to parallel expansion to other wards.Keywords: huddle, patient safety, patient care team

Shih Ping Lin,1– 3 Ching-Wein Chang,4 Chun-Yi Wu,1,5 Chun-Shih Chin,1,6 Cheng-Hsien Lin,1,7 Sz-Iuan Shiu,1,8 Yun-Wen Chen,1,9 Tsai-Hung Yen,1,9 Hui-Chi Chen,4 Yi-Hung Lai,4 Shu-Chin Hou,4 Ming-Ju Wu,3,5 Hsin-Hua Chen1,3,9– 11 1Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 2Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 3Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan; 4Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan; 5Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 6Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 7Division of Hematology and Oncology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 8Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 9Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 10Institute of Biomedical Science and Rong Hsing Research Centre for Translational Medicine, Big Data Center, Chung Hsing University, Taichung, Taiwan; 11School of Medicine, National Yang Ming Chiao Tung University, Taipei, TaiwanCorrespondence: Hsin-Hua Chen, Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan, Email shc5555@hotmail.comObjective: Huddles are short, regular debriefings that are designed to provide frontline staff and bedside caregivers environments to share problems and identify solutions. Daily huddle implementation could improve medical safety work, problem identification and improvement, situation awareness and teamwork enhancement, the collaboration and communication between professionals and departments, and patient safety. This study aimed evaluated the effectiveness of a hospital-based huddle at a general medical ward in Taiwan.Methods: A Continuous Integration team was conducted by combining multidisciplinary frontline staff to huddle at a 74-bed general medical ward. Team Huddles started twice a week. A physical huddle run board was created, which contained four parts, including idea submitted, idea approved, working on an idea and standardizing. Problems were submitted to the board to be identified, and the solutions were evaluated through huddle discussion. We divided the problems into two groups: quick hits (resolved within 24– 48hrs) and complex issues (resolved > 48hrs). An anonymous questionnaire was designed to evaluate the huddle response.Results: A total of 44 huddles occurred from September 9th, 2020, to September 30th, 2021, and 81 issues were identified and resolved. The majority issues were policy documentation (n=23; 28.4%). Sixty-seven (82.7%) issues were defined as quick hits, and the other fourteen (17.3%) issues were complex. The mean hours to the resolution of quick hits was 5.17 hours, median 3.5 hours, and range from 0.01– 15.4 hours. The mean days to resolve completion issues were 19.73 days, median 7.5 days, and range 3.57– 26.14 days. An overwhelming 92.9% of staff responded that huddles help to expedite the process to reach treatment goals, reduce clinical mistakes, near misses, reduce patient incidences, and help teamwork enhancement, with rating of 4.52 (on a 5-point Likert scale).Conclusion: Implementing of multidisciplinary team huddle improved the accountability of issue identification, problem-solving and teamwork enhancement.Keywords: huddle run, safety culture, teamwork, patient safety

Chung-Lin Lee,1– 5 Chih-Kuang Chuang,6,7 Huei-Ching Chiu,1 Ru-Yi Tu,6 Yun-Ting Lo,5 Ya-Hui Chang,1,5 Shuan-Pei Lin,1,3,5,6,8 Hsiang-Yu Lin1,3– 6,9 1Department of Pediatrics, MacKay Memorial Hospital, Taipei, Taiwan; 2Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan; 3Department of Medicine, MacKay Medical College, New Taipei City, Taiwan; 4MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan; 5Department of Rare Disease Center, MacKay Memorial Hospital, Taipei, Taiwan; 6Division of Genetics and Metabolism, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan; 7College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan; 8Department of Infant and Child Care, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan; 9Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, TaiwanCorrespondence: Shuan-Pei Lin; Hsiang-Yu LinDepartment of Pediatrics, MacKay Memorial Hospital, No. 92, Sec. 2, Chung-Shan North Road, Taipei, 10449, TaiwanTel +886-2-2543-3535 ext. 3090; +886-2-2543-3535 ext. 3089Fax +886-2-2543-3642Email 4535lin@gmail.com; lxc46199@ms37.hinet.netAbstract: Mucopolysaccharidosis type IVA (MPS IVA or Morquio A) is an autosomal recessive disorder and is one of the lysosomal storage diseases. Patients with MPS IVA have a striking skeletal phenotype but normal intellect. The phenotypic continuum of MPS IVA ranges from severe and rapid progress to mild and slow progress. The diagnosis of MPS IVA is usually suspected based on abnormal bone findings and dysplasia on physical examination and radiographic investigation in the preschool years. In the past, only supportive care was available. Due to the early and severe skeletal abnormalities, the orthopedic specialist was usually the main care provider. However, patients need aggressive monitoring and management of their systemic disease. Therefore, they need an interdisciplinary team for their care, comprising medical geneticists, cardiologists, pulmonary specialists, gastroenterologists, otolaryngologists, audiologists, and ophthalmologists. After the US Food and Drug Administration approved elosulfase alfa in 2014, patients older than 5 years could benefit from this treatment. Clinical trials showed clinically meaningful improvements with once-a-week intravenous dosing (2.0 mg/kg per week), significantly improving the 6min walk test, the 3min stair climb test, and respiratory function when compared with placebo. Elosulfase alfa is well-tolerated, and there is a good response indicated by decreasing urine glycosaminoglycans.Keywords: elosulfasealfa, enzyme replacement therapy, GALNS, lysosomal storage disorder, Morquio A, MPS IVA, mucopolysaccharidosis

Pin-Kuei Fu,1–4 Yu-Chi Tung,1 Chen-Yu Wang,2 Sheau-Feng Hwang,5,6 Shin-Pin Lin,7 Chiann-Yi Hsu,8 Duan-Rung Chen9 1Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan; 2Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 3Department of Biotechnology, Hungkuang University, Taichung, Taiwan; 4School of Chinese Medicine, China Medical University, Taichung, Taiwan; 5Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan; 6Palliative Care Unit, Taichung Veterans General Hospital, Taichung, Taiwan; 7Computer and Communications Center, Taichung Veterans General Hospital, Taichung, Taiwan; 8Biostatistics Task Force, Taichung Veterans General Hospital, Taichung, Taiwan; 9Institute of Health Behaviors and Community Sciences, National Taiwan University, Taipei, Taiwan Purpose: The unpredictable trajectory of COPD can present challenges for patients when faced with a decision regarding a do-not-resuscitate (DNR) directive. The current retrospective analysis was conducted to investigate factors associated with an early DNR decision (prior to last hospital admission) and differences in care patterns between patients who made DNR directives early vs late. Patients and methods: Electronic health records (EHR) were reviewed from 271 patients with terminal COPD who died in a teaching hospital in Taiwan. Clinical parameters, patterns of DNR decisions, and medical utilization were obtained. Those patients who had a DNR directive earlier than their last (terminal) admission were defined as “Early DNR” (EDNR). Results: A total of 234 (86.3%) patients died with a DNR directive, however only 30% were EDNR. EDNR was associated with increased age (OR=1.07; 95% CI: 1.02–1.12), increased ER visits (OR=1.22; 95% CI: 1.10–1.37), rapid decline in lung function (OR=3.42; 95% CI: 1.12–10.48), resting heart rate ≥100 (OR=3.02; 95% CI: 1.07–8.51), and right-sided heart failure (OR=2.38; 95% CI: 1.10–5.19). The median time period from a DNR directive to death was 68.5 days in EDNR patients and 5 days in “Late DNR” (LDNR) patients, respectively (P