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Introduction: The condition of trauma patients and the urgent need for timely resuscitation present unique challenges to trauma teams. These difficulties are exacerbated for military trauma teams in combat environments. Consequently, there is a need for continued improvement of nontechnical skills (NTS) training for trauma teams. However, current approaches to NTS assessment rely on subjective ratings, which can introduce bias. Accordingly, objective methods of NTS evaluation are needed. Eye-tracking (ET) methods have been applied to studying communication, situation awareness, and leadership in many health care settings, and could be applied to studying physicians' NTS during trauma situations. In this study, we aimed to assess the relationship between trauma team leaders' objective gaze patterns and subjective expert NTS ratings during patient care simulations., Materials and Methods: After Institutional Review Board approval, 9 trauma teams from first-year post-graduate general surgery and emergency medicine residents were recruited to participate in 1 of 2 trauma simulations (a difficult airway case and a multi-patient trauma). Each scenario lasted approximately 15 minutes. All team leaders wore a mobile ET system to evaluate gaze metrics-time to first fixation (TTFF), average fixation duration (AFD), and total percentage of the scenario (TPS) focused on Areas of Interest (AOI), which included patient, care team, diagnostic equipment, and patient care equipment. Trained faculty raters completed the Non-Technical Skills for Surgeons (NOTSS) assessment tool and the Trauma Non-Technical Skills (T-NOTECHS) scale. One-way analysis of variance, Kruskal-Wallis, and appropriate post-hoc pairwise comparison tests were run to assess differences between ET metrics across AOI groups. Spearman's Rho tests were used to assess correlations between ET and subjective NTS ratings., Results: Compared to other NTS domains, trauma teams scored relatively poorly on communication across both T-NOTECHS (3.29$ \pm $0.61, maximum = 5) and NOTSS (2.87$ \pm $0.66, maximum = 4). We found significant differences in trauma team leaders' TTFF between teammates and the patient (Team: 1.56 vs Patient: 29.82 seconds, P < .001). TTFF on the diagnostic equipment was negatively correlated (P < .05) to multiple measures of subjective NTS assessments. There were no significant differences in AFD between AOIs, and AFD on teammates was positively correlated (P < .05) to communication and teamwork. There were significant differences in TPS across most AOI pairs (P < .05), and the average TPS fixated was highest on the patient (32%). Finally, there were several significant correlations between additional ET and NTS metrics., Conclusions: This study utilized a mixed methods approach to assess trauma team leaders' NTS in simulated acute care trauma simulations. Our results provide several objective insights into trauma team leaders' NTS behaviors during patient care simulations. Such objective insights provide a more comprehensive understanding of NTS behaviors and can be leveraged to guide NTS training of trauma physicians in the future. More studies are needed to apply these methods to capture NTS from a larger sample of teams in both simulated and real trauma environments., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Increasing palliative care presence in the intensive care unit (ICU) improves symptom management, increases goals-of-care discussion, and reduces unnecessary procedures in ICU patients. An interdisciplinary study team developed a palliative care trigger program in a 17-bed surgical ICU (SICU). Surgical ICU patients who met 3 triggers (ICU length of stay > 10 days, repeat ICU admission, and metastatic cancer) automatically received a palliative care consult. The purpose of the current study was to survey SICU health care professionals before and after the institution of the palliative care trigger program. Overall, the palliative care trigger program was viewed positively by interdisciplinary team members with increased team communication and decreased resistance for the inclusion of palliative care in the SICU plan of care. The palliative care trigger program was successfully developed and implemented in a SICU and was accepted by the interdisciplinary team members caring for SICU patients. Team member feedback is being used to expand the palliative care trigger program to improve care for SICU patients., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 by The Hospice and Palliative Nurses Association. All rights reserved.)

Background: Early rehabilitation in intensive care units (ICUs) may be beneficial but is not routinely performed for adults with critical illness. In April 2018, the Japanese government introduced a health policy to provide financial incentives to hospitals that met the requirements of interdisciplinary collaboration and had teams specialized in ICU rehabilitation practices., Objectives: The present study aimed to investigate whether the health policy is associated with improved clinical practices of ICU rehabilitation., Methods: Using a nationwide administrative inpatient database and hospital statistics data from Japan, we identified hospitals that admitted adult patients to the ICU within two days of hospital admission from April 2016 to March 2019. Using hospital-level propensity score matching, we created matched cohorts of 101,203 patients from 108 intervention hospitals that introduced the health policy, and 106,703 patients from 108 control hospitals that did not. We then conducted patient-level difference-in-differences analyses to examine changes in the percentage of patients from the intervention and control hospitals, who underwent early ICU rehabilitation within two days of ICU admission before and after the implementation of the health policy., Results: In the intervention group, patients undergoing early ICU rehabilitation increased from 10% and 36% after the policy implementation. In the control group, it increased from 11% to 13%. The difference-in-difference in the percentage of patients who underwent early ICU rehabilitation between the two groups was 24% (95% confidence interval, 19%-29%)., Conclusions: Early ICU rehabilitation can be facilitated by financial incentives for hospitals that engage in interdisciplinary collaboration with specialist teams., Implications for Clinical Practice: Our Findings are relevant for hospital administrators, professional organizations, and policymakers in other nations considering strategies to support the additional deployment burdens of early ICU rehabilitation. Future studies need to explore the long-term effects and sustainability of the observed improvements in ICU rehabilitation practices., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background:  Teamwork and collaboration among nursing managers, nurses, doctors and peripheral hospitals treating mining patients is pivotal. A case study of specific mining primary healthcare clinics revealed a lack of teamwork among the doctors and nursing managers, even on decisions that show productivity., Objectives:  The aim of this study was to explore and describe nursing managers' perceptions of teamwork and collaboration in mining primary healthcare clinics in Gauteng., Method:  A qualitative, exploratory, descriptive and contextual research design was adopted to conduct this study. Data were collected by conducting semi-structured individual interviews with 10 participants and thematically analysed. Data saturation was reached by the seventh participant and confirmed with three more interviews. Trustworthiness measures and ethical considerations were preserved as protocols because of the nature of the study., Results:  Three themes emanated from the study: (1) team coordination and support improve teamwork and collaboration in primary healthcare clinics, (2) there is a lack of involvement from the nursing team, negatively influencing teamwork and collaboration and (3) collaboration can improve the quality of healthcare services rendered in mining primary healthcare clinics., Conclusion:  All mining primary healthcare clinic team members should be involved in operational activities to foster teamwork and collaboration.Contribution: This study revealed that teamwork and collaboration should be facilitated to improve the quality of healthcare service in mining primary healthcare clinics.

Hospital length of stay (LOS) in the USA has been increasing since the start of the COVID-19 pandemic, with numerous negative outcomes, including decreased quality of care, worsened patient satisfaction and negative financial impacts on hospitals. While many proposed factors contributing to prolonged LOS are challenging to modify, poor coordination of care and communication among clinical teams can be improved.Geographical cohorting of provider teams, patients and other clinical staff is proposed as a solution to prolonged LOS and readmissions. However, many studies on geographical cohorting alone have shown no significant impact on LOS or readmissions. Other potential benefits of geographical cohorting include improved quality of care, learning experience, communication, teamwork and efficiency.This paper presents a retrospective study at Duke University Hospital (DUH) on the General Medicine service, deploying a bundled intervention of geographical cohorting of patients and their care teams, twice daily multidisciplinary rounds and incremental case management support. The quality improvement study found that patients in the intervention arm had 16%-17% shorter LOS than those in the control arms, and there was a reduction in 30-day hospital readmissions compared with the concurrent control arm. Moreover, there was some evidence of improved accuracy of estimated discharge dates in the intervention arm.Based on these findings, the health system at DUH recognised the value of geographical cohorting and implemented additional geographically based medicine units with multidisciplinary rounds. Future studies will confirm the sustained impact of these care transformations on hospital throughput and patient outcomes, aiming to reduce LOS and enhance the quality of care provided to patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: In healthcare teams, psychological safety is associated with improved performance, communication, collaboration and patient safety. Extracorporeal membrane oxygenation (ECMO) retrieval teams are multidisciplinary teams that initiate ECMO therapy for patients with severe acute respiratory failure in referring hospitals and transfer patients to regional specialised centres for ongoing care. The present study aimed to explore an ECMO team's experience of psychological safety and generate recommendations to strengthen psychological safety., Methods: The study was conducted in the Royal Brompton Hospital (RBH), part of Guy's and St Thomas' NHS Foundation Trust in London. RBH is one of six centres commissioned to provide ECMO therapy in the UK. 10 participants were recruited: 2 consultants, 5 nurses and 3 perfusionists. Semistructured interviews were used to explore the team members' views on teamwork, their perceived ability to discuss concerns within the team and the interaction between speaking up, teamwork and hierarchy. A Reflexive Thematic Analysis approach was used to explore the interview data., Results: The analysis of the interview dataset identified structural and team factors shaping psychological safety in the specific context of the ECMO team. The high-risk environment in which the team operates, the clearly defined process and functions and the structured opportunities that provide legitimate moments to reflect together influence how psychological safety is experienced. Furthermore, speaking up is shaped by the familiarity among team members, the interdependent work, which requires boundary spanning across different roles, and leadership behaviour. A hierarchy of expertise is privileged over traditional institutional ranking., Conclusion: This study surfaced the structural and team factors that influence speaking up in the specific context of an ECMO retrieval team. Such information is used to suggest interventions to improve and strengthen psychological safety., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: In situ simulation (ISS) enables multiprofessional healthcare teams to train for real emergencies in their own working environment and identify latent patient safety threats. This study aimed to determine ISS impact on teamwork, technical skill performance, healthcare staff perception and latent error identification during simulated medical emergencies., Materials and Methods: Unannounced ISS sessions (n=14, n=75 staff members) using a high-fidelity mannequin were conducted in medical, paediatric and rehabilitation wards at Stepping Hill Hospital (Stockport National Health Service Foundation Trust, UK). Each session encompassed a 15 min simulation followed by a 15 min faculty-led debrief., Results: The clinical team score revealed low overall teamwork performances during simulated medical emergencies (mean±SEM: 4.3±0.5). Linear regression analysis revealed that overall communication (r=0.9, p<0.001), decision-making (r=0.77, p<0.001) and overall situational awareness (r=0.73, p=0.003) were the strongest statistically significant predictors of overall teamwork performance. Neither the number of attending healthcare professionals, their professional background, age, gender, degree of clinical experience, level of resuscitation training or previous simulation experience statistically significantly impacted on overall teamwork performance. ISS positively impacted on healthcare staff confidence and clinical training. Identified safety threats included unknown location of intraosseous kits, poor/absent airway management, incomplete A-E assessments, inability to activate the major haemorrhage protocol, unknown location/dose of epinephrine for anaphylaxis management, delayed administration of epinephrine and delayed/absence of attachment of pads to the defibrillator as well as absence of accessing ALS algorithms, poor chest compressions and passive behaviour during simulated cardiac arrests., Conclusion: Poor demonstration of technical/non-technical skills mandate regular ISS interventions for healthcare professionals of all levels. ISS positively impacts on staff confidence and training and drives identification of latent errors enabling improvements in workplace systems and resources., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Examine how Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) can be used to manage patient safety and improve the standard of care for patients., Methods: In order to improve key medical training in areas like surgical safety management, blood transfusion closed-loop management, drug safety management and identity recognition, we apply the TeamSTEPPS teaching methodology. We then examine the effects of this implementation on changes in pertinent indicators., Results: Our hospital's perioperative death rate dropped to 0.019%, unscheduled reoperations dropped to 0.11%, and defined daily doses fell to 24.85. Antibiotic usage among hospitalised patients declined to 40.59%, while the percentage of antibacterial medicine prescriptions for outpatient patients decreased to 13.26%. Identity recognition requirements were implemented at a rate of 94.5%, and the low-risk group's death rate dropped to 0.01%. Critical transfusion episodes were less common, with an incidence of 0.01%. The physician's TeamSTEPPS Teamwork Perceptions Questionnaire and Teamwork Attitudes Questionnaire scores dramatically improved following the TeamSTEPPS team instruction course., Conclusion: An evidence-based team collaboration training programme called TeamSTEPPS combines clinical practice with team collaboration skills to enhance team performance in the healthcare industry and raise standards for medical quality, safety, and effectiveness., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist., Objective: To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD., Design, Setting, and Participants: This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022., Exposure: Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services., Measures: Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods., Results: Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care., Conclusions and Relevance: The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.

Introduction: Pulmonary embolism (PE) is associated with significant rates of morbidity and mortality. Management of PE is complex, and adverse patient events are not uncommon. Brooke Army Medical Center (BAMC) is among several select institutions that have implemented multidisciplinary pulmonary embolism response teams (PERTs) to improve PE outcomes. PERT structure varies among institutions and often involves specialty expertise from a variety of departments within the hospital. PE response teams aim to improve the diagnosis and treatment for patients with acute PE. Here, we report our initial experience with this intervention., Materials and Methods: We developed a multidisciplinary PERT and implemented a standardized algorithm to guide the evaluation, management, and disposition of patients with acute PE. Patients with PE were identified in the pre-PERT period (2015-2017) and the post-PERT period (2020-2021). A retrospective analysis of clinical characteristics, management strategies, and outcomes was performed for both cohorts., Results: A total of 68 patients with acute PE were analyzed, 38 patients before PERT adoption, and 30 patients post-PERT. Baseline characteristics between the two cohorts were similar. A statistically significant increase in the evaluation for right ventricle dysfunction was noted in the post-PERT cohort, with 80% of patients having pro-brain natriuretic peptide labs obtained compared to 47% in the pre-PERT cohort (P = .005). Furthermore, 97% of patients in the post-PERT cohort had a transthoracic echocardiogram compared to 55% in the pre-PERT cohort (P = .0001). Six patients in the pre-PERT cohort underwent catheter-directed thrombolysis, compared to zero in the post-PERT cohort (P = .006). There were no differences in other treatment modalities. There was no statistically significant difference in length of stay between the two cohorts., Conclusions: To our knowledge, this is the first report describing the successful implementation of a PERT at a military treatment facility to guide the evaluation, management, and treatment of PE. The implementation of the PERT improved the appropriate diagnostic evaluation for patients with intermediate-risk PE and reduced the use of non-guideline-based catheter-directed thrombolysis. This initiative serves as an example of what could be applied across other military treatment facilities within the Defense Health Agency., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objectives: To determine the impact of coronavirus disease 2019 on burnout syndrome in the multiprofessional ICU team and to identify factors associated with burnout syndrome., Design: Longitudinal, cross-sectional survey., Setting: All adult ICUs within an academic health system., Subjects: Critical care nurses, advanced practice providers, physicians, respiratory therapists, pharmacists, social workers, and spiritual health workers were surveyed on burnout in 2017 and during the coronavirus disease 2019 pandemic in 2020., Interventions: None., Measurements and Main Results: Burnout syndrome and contributing factors were measured using the Maslach Burnout Inventory of Health and Human Service and Areas of Worklife Survey. Response rates were 46.5% (572 respondents) in 2017 and 49.9% (710 respondents) in 2020. The prevalence of burnout increased from 59% to 69% (p < 0.001). Nurses were disproportionately impacted, with the highest increase during the pandemic (58-72%; p < 0.0001) with increases in emotional exhaustion and depersonalization, and personal achievement decreases. In contrast, although burnout was high before and during coronavirus disease 2019 in all specialties, most professions had similar or lower burnout in 2020 as they had in 2017. Physicians had the lowest rates of burnout, measured at 51% and 58%, respectively. There was no difference in burnout between clinicians working in ICUs who treated coronavirus disease 2019 than those who did not (71% vs 67%; p = 0.26). Burnout significantly increased in females (71% vs 60%; p = 0.001) and was higher than in males during the pandemic (71% vs 60%; p = 0.01)., Conclusions: Burnout syndrome was common in all multiprofessional ICU team members prior to and increased substantially during the pandemic, independent of whether one treated coronavirus disease 2019 patients. Nurses had the highest prevalence of burnout during coronavirus disease 2019 and had the highest increase in burnout from the prepandemic baseline. Female clinicians were significantly more impacted by burnout than males. Different susceptibility to burnout syndrome may require profession-specific interventions as well as work system improvements., Competing Interests: Dr. Pappas received funding from the American Organization for Nursing Leaders; she disclosed that she holds a seat on the Commission on Magnet with the American Nursing Credentialing Center. Dr. Buchman’s institution received funding from the Society of Critical Care Medicine and the U.S. Government. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: Approximately 40-70% of people with Parkinson's disease (PD) fall each year, causing decreased activity levels and quality of life. Current fall-prevention strategies include the use of pharmacological and non-pharmacological therapies. To increase the accessibility of this vulnerable population, we developed a multidisciplinary telemedicine program using an Information and Communication Technology (ICT) platform. We hypothesized that the risk for falling in PD would decrease among participants receiving a multidisciplinary telemedicine intervention program added to standard office-based neurological care., Objective: To determine the feasibility and cost-effectiveness of a multidisciplinary telemedicine intervention to decrease the incidence of falls in patients with PD., Methods: Ongoing, longitudinal, randomized, single-blinded, case-control, clinical trial. We will include 76 non-demented patients with idiopathic PD with a high risk of falling and limited access to multidisciplinary care. The intervention group (n = 38) will receive multidisciplinary remote care in addition to standard medical care, and the control group (n = 38) standard medical care only. Nutrition, sarcopenia and frailty status, motor, non-motor symptoms, health-related quality of life, caregiver burden, falls, balance and gait disturbances, direct and non-medical costs will be assessed using validated rating scales., Results: This study will provide a cost-effectiveness assessment of multidisciplinary telemedicine intervention for fall reduction in PD, in addition to standard neurological medical care., Conclusion: In this challenging initiative, we will determine whether a multidisciplinary telemedicine intervention program can reduce falls, as an alternative intervention option for PD patients with restricted access to multidisciplinary care., Trial Registration: ClinicalTrials.gov Identifier: NCT04694443., Competing Interests: the authors declare we have received funding from NVIDIA Corporation. However, authors declare that they were free for publication, and they do not have relevant declarations relating to employment, consultancy, patents, products in development, or marketed products In addition, this does not alter our adherence to PLOS ONE policies on sharing data and materials

Background and Methods: Treatment strategies for pancreatic cancer patients are made by a multidisciplinary team (MDT) board. We aimed to assess intra-observer variance at MDT boards. Participating units staged, assessed resectability, and made treatment allocations for the same patients as they did two years earlier. We disseminated clinical information and CT images of pancreatic cancer patients judged by one MDT board to have nonmetastatic pancreatic cancer to the participating units. All units were asked to re-assess the TNM stage, resectability, and treatment allocation for each patient. To assess intra-observer variance, we computed %-agreements for each participating unit, defined as low (<50%), moderate (50%-75%), and high (>75%) agreement., Results: Eighteen patients were re-assessed by six MDT boards. The overall agreement was moderate for TNM-stage (ranging from 50%-70%) and resectability assessment (53%) but low for treatment allocation (46%). Agreement on resectability assessments was low to moderate. Findings were similar but more pronounced for treatment allocation. We observed a shift in treatment strategy towards increasing use of neoadjuvant chemotherapy, particularly in patients with borderline resectable and locally advanced tumors., Conclusions: We found substantial intra-observer agreement variations across six different MDT boards of 18 pancreatic cancer patients with two years between the first and second assessment., (© 2021 Wiley Periodicals LLC.)

Objective: To analyse the impact of the COVID-19 pandemic on a centralized specialist kidney cancer care pathway., Materials and Methods: We conducted a retrospective analysis of patient and pathway characteristics including prioritization strategies at the Specialist Centre for Kidney Cancer located at the Royal Free London NHS Foundation Trust (RFH) before and during the surge of COVID-19., Results: On 18 March 2020 all elective surgery was halted at RFH to redeploy resources and staff for the COVID-19 surge. Prioritizing of patients according to European Association of Urology guidance was introduced. Clinics and the specialist multidisciplinary team (SMDT) meetings were maintained with physical distancing, kidney surgery was moved to a COVID-protected site, and infection prevention measurements were enforced. During the 7 weeks of lockdown (23 March to 10 May 2020), 234 cases were discussed at the SMDT meetings, 53% compared to the 446 cases discussed in the 7 weeks pre-lockdown. The reduction in referrals was more pronounced for small and asymptomatic renal masses. Of 62 low-priority cancer patients, 27 (43.5%) were deferred. Only one (4%) COVID-19 infection occurred postoperatively, and the patient made a full recovery. No increase in clinical or pathological upstaging could be detected in patients who underwent deferred surgery compared to pre-COVID practice., Conclusion: The first surge of the COVID-19 pandemic severely impacted diagnosis, referral and treatment of kidney cancer at a tertiary referral centre. With a policy of prioritization and COVID-protected pathways, capacity for time-sensitive oncological interventions was maintained and no immediate clinical harm was observed., (© 2021 The Authors BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

Background: Although 40 years has passed since the Institute of Medicine released its report "To Err Is Human," error counts are still high in healthcare. The understanding and training of nontechnical skills and teamwork thus remains a pertinent area for improvement. Most evaluation of nontechnical skills of trauma teams takes place in simulation rooms. The aim of this study was to determine if real trauma resuscitation communication could be analyzed using the speech classification system of verbal response modes, otherwise known as the verbal response mode taxonomy and, if so, if there is a predominant approach of verbally delivering messages., Methods: Video and audio recordings of 5 trauma team resuscitations were transcribed. Communication was coded using the verbal response mode taxonomy for both form and intent. The rate of mixed-mode communication (unmatched form and intent) and pure-mode communication were calculated and compared between the participants roles. Comparisons were made with simulated material published in other research., Results: The most frequent mixed-mode communication was acknowledgment in service of confirmation. Question in service of a question was the most used pure-mode communication. Six predominant roles were seen, which matched well with the roles in the simulations., Conclusion: The verbal response mode taxonomy can be used to study communication during real trauma resuscitation, and it was found that pure-mode communication was predominant, meaning that the grammatical form matches the intent. Verbal response mode methodology is time consuming and requires analysts with domain knowledge. Comparisons show some differences between simulations and our material indicating that verbal response modes can be used to evaluate differences in communication., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: This retrospective study examined how a pharmacist-involved education program in a multidisciplinary team (PEMT) for oral mucositis (OM) affected head-and-neck cancer (HNC) patients receiving concurrent chemoradiotherapy (CCRT)., Materials and Methods: Total samples data of 53 patients during the stipulated timeframe were retrospectively collected from electronic medical records from February 2017 to January 2019. We compared the presence/absence of OM (OM: yes/no) between patients with and without PEMT (PEMT: yes/no) as the primary endpoint and OM severity as the secondary endpoint. The following information was surveyed: age, gender, weight loss, steroid or immunosuppressant use, hematological values (albumin, white blood cell count, blood platelets, and neutrophils), cancer grade, primary cancer site, type and use of mouthwash and moisturizer, opioid use (yes/no, days until the start of opioid use, and dose, switch to tape), and length of hospital day (LOD). The two groups were compared using Fisher's exact test for qualitative data and the Mann-Whitney U test for quantitative data, and a significance level of p<0.05 was set., Results: The group managed by PEMT had significantly lower weight loss and a significantly lower incidence of local anesthetic and opioid use and switch to tape compared with the group not managed by PEMT (p<0.05). The two groups showed no significant difference in OM (yes/no) or OM severity. The PEMT group had significantly shorter LOD at 57 (53-64) days compared with the non-PEMT group at 63.5 (57-68) days (p<0.05)., Conclusions: Our results showed that PEMT did not improve OM (yes/no) or OM severity in HNC patients undergoing CCRT. However, the PEMT group had a lower incidence of grades 3 and 4 OM than the non-PEMT group, although not significantly. In addition, PEMT contributed to oral pain relief and the lowering of the risk for OM by reduction in weight loss., Competing Interests: The authors have declared that no competing interests exist.

Importance: Telehealth use including secure messages has rapidly expanded since the COVID-19 pandemic, including for multidisciplinary aspects of cancer care. Recent reports described rapid uptake and various benefits for patients and clinicians, suggesting that telehealth may be in standard use after the pandemic., Objective: To examine attitudes and perceptions of multidisciplinary cancer care clinicians toward telehealth and secure messages., Design, Setting, and Participants: Cross-sectional specialty-specific survey (ie, some questions appear only for relevant specialties) among multidisciplinary cancer care clinicians, collected from April 29, 2020, to June 5, 2020. Participants were all 285 clinicians in the fields of medical oncology, radiation oncology, surgical oncology, survivorship, and oncology navigation from all 21 community cancer centers of Kaiser Permanente Northern California., Main Outcomes and Measures: Clinician satisfaction, perceived benefits and challenges of telehealth, perceived quality of telehealth and secure messaging, preferred visit and communication types for different clinical activities, and preferences regarding postpandemic telehealth use., Results: A total of 202 clinicians (71%) responded (104 of 128 medical oncologists, 34 of 37 radiation oncologists, 16 of 62 breast surgeons, 18 of 28 navigators, and 30 of 30 survivorship experts; 57% (116 of 202) were women; 73% [147 of 202] between ages 36-55 years). Seventy-six percent (n = 154) were satisfied with telehealth without statistically significant variations based on clinician characteristics. In-person visits were thought to promote a strong patient-clinician connection by 99% (n = 137) of respondents compared with 77% (n = 106) for video visits, 43% (n = 59) for telephone, and 14% (n = 19) for secure messages. The most commonly cited benefits of telehealth to clinicians included reduced commute (79%; n = 160), working from home (74%; n = 149), and staying on time (65%; n = 132); the most commonly cited negative factors included internet connection (84%; n = 170) or equipment problems (72%; n = 146), or physical examination needed (64%; n = 131). Most respondents (59%; n = 120) thought that video is adequate to manage the greater part of patient care in general; and most deemed various telehealth modalities suitable for any of the queried types of patient-clinician activities. For some specific activities, less than half of respondents thought that only an in-person visit is acceptable (eg, 49%; n = 66 for end-of-life discussion, 35%; n = 58 for new diagnosis). Most clinicians (82%; n = 166) preferred to maintain or increase use of telehealth after the pandemic., Conclusions and Relevance: In this survey of multidisciplinary cancer care clinicians in the COVID-19 era, telehealth was well received and often preferred by most cancer care clinicians, who deemed it appropriate to manage most aspects of cancer care. As telehealth use becomes routine in some cancer care settings, video and telephone visits and use of asynchronous secure messaging with patients in cancer care has clear potential to extend beyond the pandemic period.

Background: Changes in discharge disposition and delays in discharge negatively impact the patient and hospital system. Our objectives were 1 to determine the accuracy with which trauma and emergency general surgery (TEGS) providers could predict the discharge disposition for patients and 2 determine the factors associated with incorrect predictions., Methods: Discharge dispositions and barriers to discharge for 200 TEGS patients were predicted individually by members of the multidisciplinary TEGS team within 24 h of patient admission. Univariate analyses and multivariable logistic least absolute shrinkage and selection operator regressions determined the associations between patient characteristics and correct predictions., Results: A total of 1,498 predictions of discharge disposition were made by the multidisciplinary TEGS team for 200 TEGS patients. Providers correctly predicted 74% of discharge dispositions. Prediction accuracy was not associated with clinical experience or job title. Incorrect predictions were independently associated with older age (OR 0.98; P < 0.001), trauma admission as compared to emergency general surgery (OR 0.33; P < 0.001), higher Injury Severity Scores (OR 0.96; P < 0.001), longer lengths of stay (OR 0.90; P < 0.001), frailty (OR 0.43; P = 0.001), ICU admission (OR 0.54; P < 0.001), and higher Acute Physiology and Chronic Health Evaluation II scores (OR 0.94; P = 0.006)., Conclusion: The TEGS team can accurately predict the majority of discharge dispositions. Patients with risk factors for unpredictable dispositions should be flagged to better allocate appropriate resources and more intensively plan their discharges., (Copyright © 2021. Published by Elsevier Inc.)

Introduction: Multidisciplinary team (MDT) assessment is associated with improved survival in locally advanced rectal cancer, but the effect of an MDT assessment on survival in locally advanced colon cancer has not been reported. The aim of this national population-based cohort study was to establish if preoperative MDT assessment affects prognosis in patients with primary locally advanced colon cancer., Material and Methods: All patients in Sweden with locally advanced colon cancer, without metastatic disease, who underwent an elective colon resection between 2010 and 2017 were identified through the Swedish Colorectal Cancer Registry (SCRCR), and the cohort was linked to national registers. Data on patient characteristics, preoperative staging, surgical procedures, recurrence and survival were collected from SCRCR. The association between MDT assessment and colon cancer-specific survival was evaluated using Kaplan-Meier survival curves and Cox proportional hazards models. The multivariable analysis was adjusted for sex, age, ASA grade, CCI, time period, pN, region and preoperative MDT., Results: MDT assessment was performed in 2663 patients (84.4%) of 3157 eligible patients. The 3-year colon cancer-specific survival was higher following MDT, compared with no MDT assessment (80% versus 68%). MDT assessment was independently associated with reduced colon cancer-specific mortality (HR 0.70, 0.57-0.84 95% CI)., Conclusion: Preoperative MDT assessment is associated with an improved long-term survival in patients with locally advanced colon cancer and should be mandatory in patients with suspected locally advanced colon cancer., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

There is little data on the experience of managing pediatric Intestinal Failure (IF) in Latin America. This study aimed to identify and describe the current organization and practices of the IF teams in Latin America and the Caribbean. An online survey was sent to inquire about the existence of IF teams that managed children on home parenteral nutrition (HPN). Our questionnaire was based on a previously published European study with a similar goal. Twenty-four centers with pediatric IF teams in eight countries completed the survey, representing a total number of 316 children on HPN. The median number of children on parenteral nutrition (PN) at home per team was 5.5 (range 1-50). Teams consisted of the following members: pediatric gastroenterologist and a pediatric surgeon in all teams, dietician (95.8%), nurse (91.7%), social worker (79.2%), pharmacist (70.8%), oral therapist (62.5%), psychologist (58.3%), and physiotherapist (45.8%). The majority of the centers followed international standards of care on vascular access, parenteral and enteral nutrition, and IF medical and surgical management, but a significant percentage reported inability to monitor micronutrients, like vitamins A (37.5%), E (41.7%), B1 (66.7%), B2 (62.5%), B6 (62.5%), active B12 (58.3%); and trace elements-including zinc (29.2%), aluminum (75%), copper (37.5%), chromium (58.3%), selenium (58.3%), and manganese (58.3%). Conclusion: There is wide variation in how IF teams are structured in Latin America-while many countries have well-established Intestinal rehabilitation programs, a few do not follow international standards. Many countries did not report having an IF team managing pediatric patients on HPN.

Expanding the US Food and Drug Administration-approved indications for immune checkpoint inhibitors in patients with cancer has resulted in therapeutic success and immune-related adverse events (irAEs). Neurologic irAEs (irAE-Ns) have an incidence of 1%-12% and a high fatality rate relative to other irAEs. Lack of standardized disease definitions and accurate phenotyping leads to syndrome misclassification and impedes development of evidence-based treatments and translational research. The objective of this study was to develop consensus guidance for an approach to irAE-Ns including disease definitions and severity grading. A working group of four neurologists drafted irAE-N consensus guidance and definitions, which were reviewed by the multidisciplinary Neuro irAE Disease Definition Panel including oncologists and irAE experts. A modified Delphi consensus process was used, with two rounds of anonymous ratings by panelists and two meetings to discuss areas of controversy. Panelists rated content for usability, appropriateness and accuracy on 9-point scales in electronic surveys and provided free text comments. Aggregated survey responses were incorporated into revised definitions. Consensus was based on numeric ratings using the RAND/University of California Los Angeles (UCLA) Appropriateness Method with prespecified definitions. 27 panelists from 15 academic medical centers voted on a total of 53 rating scales (6 general guidance, 24 central and 18 peripheral nervous system disease definition components, 3 severity criteria and 2 clinical trial adjudication statements); of these, 77% (41/53) received first round consensus. After revisions, all items received second round consensus. Consensus definitions were achieved for seven core disorders: irMeningitis, irEncephalitis, irDemyelinating disease, irVasculitis, irNeuropathy, irNeuromuscular junction disorders and irMyopathy. For each disorder, six descriptors of diagnostic components are used: disease subtype, diagnostic certainty, severity, autoantibody association, exacerbation of pre-existing disease or de novo presentation, and presence or absence of concurrent irAE(s). These disease definitions standardize irAE-N classification. Diagnostic certainty is not always directly linked to certainty to treat as an irAE-N (ie, one might treat events in the probable or possible category). Given consensus on accuracy and usability from a representative panel group, we anticipate that the definitions will be used broadly across clinical and research settings., Competing Interests: Competing interests: ACG has served on an advisory board and/or consulted with Alexion, Ra Pharma/UCB and Momenta pharmaceuticals/Janssen. She has received royalties from Oakstone Publishing and research support from the Myasthenia Gravis Foundation of America, the MG Rare Disease Network and Project Data Sphere® for an irAE-N registry. She has received clinical trial support to the institution from Ra Pharma and Momenta. LBB receives salary support from Biogen, royalties from Oakstone Publishing, and research support from Project Data Sphere for an irAE-N registry. BKC reports research support from Project Data Sphere for an irAE-N registry. JH receives research support from Project Data Sphere for an irAE-N registry and from GE Healthcare. THS is an employee at the not-for-profit corporation Project DS, with a trade name of Project Data Sphere. AAA served on medical advisory boards for Alexion, Sarepta, CSL Behring, Strongbridge Pharma, Argenx, Ra Pharmaceuticals, and as a neurology consultant for Johnson & Johnson COVID-19 vaccine trials. ABW served on a medical advisory board or as a consultant with Iovance, Novartis, Shanghai Jo’Ann Medical Technology. PKB has consulted for Angiochem, Genentech-Roche, Lilly, Tesaro, Voyager Therapeutics, ElevateBio, Pfizer (Array), Pfizer, SK Life Sciences and Dantari, received grant/research support (to Massachusetts General Hospital) from Merck, BMS and Lilly and honoraria from Merck, Pfizer, Genentech-Roche and Lilly. TAC has received royalties from Wolters Kluwer. SLC serves as the Editor of the Neurology®Podcast and Neurology Minute™. She has received research and/or clinical fellowship support from the Western Institute for Veterans Research, the Siegel Rare Neuroimmune Association, the Immune Deficiency Foundation, Alexion, the Barbara Gural Steinmetz Foundation, and the Sumaira Foundation for NMO. She has served on an advisory board and/or consulted with Alexion, Genentech, VielaBio, Guidepoint, Clarion Healthcare Consulting, ExpertConnect (majority fees paid to University of Utah). JC has received consulting fees from Sanofi-Genzyme and BMS. JD is a consultant for Blue Earth Diagnostics, Magnolia, Gamaka Bio, and Unum Therapeutics. JD has received research support from Beacon Biosignals, Boehringer Ingelheim, Brystol-Myers Squibb, Eli Lilly, Medimmune, Acerta Pharma, Orbus Therapeutics, and Novartis Pharmaceuticals. JD has received royalties from Wolters Kluwer for serving as an author for UpToDate. MD has research funding from Novartis and Eli Lilly, has served as a consultant for Roche-Genentech, Tillotts Pharma, ORIC Pharmaceuticals, Partner Therapeutics, and Moderna, and is a member of the Scientific Advisory Board for Neoleukin Therapeutics. CTD has served on advisory boards for Argenx and Dysimmune Diseases Foundation. He has received royalties from Oakstone Publishing. He has received grant support from NINDS/NeuroNext. DD has served on an advisory board and/or consulted for UCB, Astellas and Immunovant pharmaceuticals. All compensation for the consulting activities is paid to Mayo Clinic. He has patents pending for KLHL11 and LUZP4 as markers of neurological autoimmunity and germ cell tumors. JG has received research to UCSF support from Genentech/Roche for a clinical trial, performed consulting for Biogen, and received personal compensation for medical-legal consulting. JTG has served as a consultant in past 12 months for Immunovant, Alexion, Momenta, Ra Pharma, Grifols, Jacobus, Cabaletta, Regeneron, Argenx, Signant, UCB, Toleranzia and Piedmont Pharmaceuticals. He receives industry grant support from UCB pharma for a fellowship training grant. Full disclosure statement available at: https://dcri.org/about-us/conflict-of-interest/. DBJ has served on advisory boards for Array Biopharma, BMS, Catalyst Biopharma, Iovance, Jansen, Merck, Novartis, and Oncosec, and has received research funding from BMS and Incyte. VCJ is a site investigator in myasthenia gravis research trials sponsored by PCORI and by Alexion Pharmaceuticals. RK receives research funding from Alexion Pharmaceuticals. NK reports no relevant disclosures. NRL is a consultant and has received honoraria from Bayer, Seattle Genetics, Sanofi, Fortress Biotech, Silverback Therapeutics and SYNOX Therapeutics. JL reports no disclosures. AM reports no disclosures. MM-L reports no relevant disclosures. MJM has served on an advisory board and/or consulted with AstraZeneca Pharmaceuticals, Nektar Therapeutics, Catalyst Pharmaceuticals and Immunai. JN has received research funding from Merck and AstraZeneca; served as a consultant/advisory board member with Merck, AstraZeneca, BMS, Pfizer, Takeda, Roche/Genentech, Daiichi/Sankyo and has received honoraria from Merck, AstraZeneca, BMS, Pfizer, Takeda, Roche/Genentech. TGN reports acting as a consultant for Parexel, Bristol Myers-Squibb, H3 Biomedicine, AbbVie, and Intrinsic Imaging unrelated to the current research. TGN reports grant funding from AstraZeneca unrelated to current research. DR has been an advisor or consultant with AbbVie; Advantagene; Agenus; Agios; Amgen; Bayer; Boston Biomedical; Boehringer Ingelheim; Bristol-Myers Squibb; Celldex; Deciphera; DelMar; EMD Serono; Genenta; Genentech/Roche; Imvax; Inovio; Kintara; Kiyatec; Medicenna Biopharma; Merck; Merck KGaA; Monteris; Neuvogen; Novartis; Novocure; Oncorus; Oxigene; Regeneron; Stemline; Sumitono Dainippon Pharma; Taiho Oncology. Research support to his institution has been provided by Acerta Phamaceuticals; Agenus; Celldex; EMD Serono; Incyte; Inovio; Omniox; Tragara. KMR has served on an advisory board and/or consulted with Merck, BMS, and Eisai. BDS has served on an advisory board and/or consulted with Janssen, Kite/Gilead, and Celgene/BMS. RS has served on an advisory board and/or consulted with AstraZeneca, Bristol-Myers Squib, Eisai, Iovance, Merck, Novartis, Oncosec, Pfizer, and Replimune. He has received research funding from Merck. NW has served on an advisory board with Seattle Genetics, received royalties from Wolters Kluwer and research support from Merck. KW reports no disclosures. LZ has been a consultant for Merck. WCL is an employee of the not-for-profit corporation Project DS, with a trade name of Project Data Sphere. KLR has received personal compensation from Teladoc research support from Project Data Sphere for a irAE-N registry., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Environmental noise pollution is regarded as a general stressor. Noise levels frequently exceed recommended noise levels by the World Health Organization in hospitals, especially in the operation room. The aim of this systematic review was to assess the effects of noise pollution on patient outcome and performance by operation room staff. In addition, the perception and attitude toward playing music in the operation room, which can increase noise levels, were assessed as well., Materials and Methods: A systematic literature search of the databases Embase, Medline Ovid, and Cochrane from date of database inception until October 16 th , 2020 using the exhaustive literature search method was performed. Prospective studies evaluating the effect of noise on the patient, surgeons, anesthesiologists, nurses, and other operation room staff, or perception and attitude toward playing music in the operation room, were included. This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines and was registered with PROSPERO (ID: 208282)., Results: The literature search generated 4758 articles, and 22 prospective studies (3507 participants) were included. Three of the four studies that investigated the effect of noise on patient outcome reported a significant reduction of complication rate in surgical patients, when noise levels were lower. Six studies assessed the effect of noise in the operation room on the staff (1383 participants). Over half of the surveyed staff found noise levels to be a disturbing stressor and negatively impact performance. Although music increased decibel levels in the operation room, most surveyed staff was positively predisposed toward playing music during surgery, believing it to improve both individual and team performance. In general, music was not considered to be distracting or impairing communication., Conclusions: Higher noise levels seem to have a negative effect on patient outcome and adversely affect performance by members in the operation room. Further research is needed to assess whether this knowledge can benefit patient outcome and surgical performance. Notably, attitude of surgical team members toward music during surgery is generally regarded favorable., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Aims: Despite the evidence available on the epidemiology of diabetic foot ulcers and associated complications, it is not clear how specific organizational aspects of health care systems can positively affect their clinical trajectory. We aim to evaluate the impact of organizational aspects of care on lower extremity amputation rates among people with type 2 diabetes affected by foot ulcers., Methods: We conducted a systematic review of the scientific literature published between 1999 and 2019, using the following key terms as search criteria: people with type 2 diabetes, diagnosed with diabetic foot ulcer, treated with specific processes and care pathways, and LEA as primary outcome. Overall results were reported as pooled odds ratios and 95% confidence intervals obtained using fixed and random effects models., Results: A total of 57 studies were found eligible, highlighting the following arrangements: dedicated teams, care pathways and protocols, multidisciplinary teams, and combined interventions. Among them, seven studies qualified for a meta-analysis. According to the random effects model, interventions including any of the four arrangements were associated with a 29% reduced risk of any type of lower extremity amputation (OR = 0.71; 95% CI 0.52-0.96). The effect was larger when focusing on major LEAs alone, leading to a 48% risk reduction (OR = 0.52; 95% CI 0.30-0.91)., Conclusions: Specific organizational arrangements including multidisciplinary teams and care pathways can prevent half of the amputations in people with diabetes and foot ulcers. Further studies using standardized criteria are needed to investigate the cost-effectiveness to facilitate wider implementation of improved organizational arrangements. Similarly, research should identify specific roadblocks to translating evidence into action. These may be structures and processes at the health system level, e.g. availability of professionals with the right skillset, reimbursement mechanisms, and clear organizational intervention implementation guidelines.

Background: Spatial inequalities in cancer management have been evidenced by studies reporting lower quality of care or/and lower survival for patients living in remote or socially deprived areas. NETSARC+ is a national reference network implemented to improve the outcome of sarcoma patients in France since 2010, providing remote access to specialized diagnosis and Multidisciplinary Tumour Board (MTB). The IGéAS research program aims to assess the potential of this innovative organization, with remote management of cancers including rare tumours, to go through geographical barriers usually impeding the optimal management of cancer patients., Methods: Using the nationwide NETSARC+ databases, the individual, clinical and geographical determinants of the access to sarcoma-specialized diagnosis and MTB were analysed. The IGéAS cohort (n = 20,590) includes all patients living in France with first sarcoma diagnosis between 2011 and 2014. Early access was defined as specialised review performed before 30 days of sampling and as first sarcoma MTB discussion performed before the first surgery., Results: Some clinical populations are at highest risk of initial management without access to sarcoma specialized services, such as patients with non-GIST visceral sarcoma for diagnosis [OR 1.96, 95% CI 1.78 to 2.15] and MTB discussion [OR 3.56, 95% CI 3.16 to 4.01]. Social deprivation of the municipality is not associated with early access on NETSARC+ remote services. The quintile of patients furthest away from reference centres have lower chances of early access to specialized diagnosis [OR 1.18, 95% CI 1.06 to 1.31] and MTB discussion [OR 1.24, 95% CI 1.10 to 1.40] but this influence of the distance is slight in comparison with clinical factors and previous studies on the access to cancer-specialized facilities., Conclusions: In the context of national organization driven by reference network, distance to reference centres slightly alters the early access to sarcoma specialized services and social deprivation has no impact on it. The reference networks' organization, designed to improve the access to specialized services and the quality of cancer management, can be considered as an interesting device to reduce social and spatial inequalities in cancer management. The potential of this organization must be confirmed by further studies, including survival analysis.

Background: The emergency medical service as a high-risk workplace is a danger to patient safety. A main factor for patient safety, but also at the same time a main factor for patient harm, is team communication. Team communication is multidimensional and occurs before, during, and after the patient's treatment., Methods: In an online based, anonymous and single-blinded study, medical and non-medical employees in the emergency medical services were asked about team communication, and communication errors., Results: Seven hundred and fourteen medical and non-medical rescue workers from all over Germany took part. Among them, 72.0% had harmed at least one patient during their work. With imprecise communication, 81.7% rarely asked for clarification. Also, 66.3% saw leadership behavior as the cause of poor communication; 46.0% could not talk to their superiors about errors. Of note, 96.3% would like joint training of medical and non-medical employees in communication., Conclusion: Deficits in team communication occur frequently in the rescue service. There is a clear need for uniform training in team and communication skills in all professions., Competing Interests: The authors have declared that no competing interests exist.

Purpose: The purpose of the current meta-analysis was to evaluate whether multidisciplinary team improved overall survival of colorectal cancer., Methods: PubMed, EMBASE, and Cochrane Library database were searched from inception to October 25, 2020. The hazard ratio (HR) and 95% confidence (CI) of overall survival (OS) were calculated., Results: A total of 11 studies with 30814 patients were included in this meta-analysis. After pooling the HRs, the MDT group was associated with better OS compared with the non-MDT group (HR = 0.81, 95% CI 0.69-0.94, p = 0.005). In subgroup analysis of stage IV colorectal cancer, the MDT group was associated with better OS as well (HR = 0.73, 95% CI 0.59-0.90, p = 0.004). However, in terms of postoperative mortality, no significant difference was found between MDT and non-MDT groups (OR = 0.84, 95% CI 0.44-1.61, p = 0.60)., Conclusion: MDT could improve OS of colorectal cancer patients., Competing Interests: The authors declare that they have no conflict of interest., (Copyright © 2021 Dong Peng et al.)

Background: Leaders from a university, Area Health Education Center, and primary care centers (PCCs) collaborated to integrate Interprofessional Collaborative Practice (IPCP) in PCCs., Purpose: Describe the facilitators and barriers of IPCP implementation in rural clinics and the impact on decision-making and safety culture., Methods: The implementation team used engagement strategies to support the development of IPCP. PCC team participants completed surveys measuring collaboration and satisfaction with care decisions and safety culture. Qualitative data were analyzed to describe facilitators and barriers to IPCP., Findings: Significant improvement (p < .035) in the Global Amount of Collaboration made over time. Barriers to IPCP included high turnover, hierarchical culture, lack of role clarity, competing time demands, limited readiness for change, and physical space limitations. Facilitators included structured huddles, alignment of IPCP with organizational goals, and academic-practice partnership., Discussion: Partnering with academic-practice partnerships may facilitate collaboration and team learning as PCCs incorporate IPCP into practice., (Copyright © 2020 Elsevier Inc. All rights reserved.)

There is a persistent variation in cancer outcomes among and within European countries suggesting (among other causes) inequalities in access to or delivery of high-quality cancer care. European policy (EU Cancer Mission and Europe's Beating Cancer Plan) is currently moving towards a mission-oriented approach addressing these inequalities. In this study, we used the quantitative and qualitative data of the Organisation of European Cancer Institutes' Accreditation and Designation Programme, relating to 40 large European cancer centres, to describe their current compliance with quality standards, to identify the hallmarks common to all centres and to show the distinctive features of Comprehensive Cancer Centres. All Comprehensive Cancer Centres and Cancer Centres accredited by the Organisation of European Cancer Institutes show good compliance with quality standards related to care, multidisciplinarity and patient centredness. However, Comprehensive Cancer Centres on average showed significantly better scores on indicators related to the volume, quality and integration of translational research, such as high-impact publications, clinical trial activity (especially in phase I and phase IIa trials) and filing more patents as early indicators of innovation. However, irrespective of their size, centres show significant variability regarding effective governance when functioning as entities within larger hospitals., (© 2021 The Authors. Molecular Oncology published by John Wiley & Sons Ltd on behalf of Federation of European Biochemical Societies.)

Introduction: The organization of the healthcare system has significantly changed after the recent COVID-19 outbreak, with a negative impact on the management of oncological patients. The present survey reports data collected by the Italian Association for Neuroendocrine Tumors on the management of patients with neuroendocrine neoplasia (NEN) during the pandemic dissemination., Methods: A survey with 57 questions was sent to NEN-dedicated Italian centers regarding the management of patients in the period March 9, 2020, to May 9, 2020 RESULTS: The main modification in the centers' activity consisted of decreases in newly diagnosed NEN patients (- 76.8%), decreases in performed surgical procedures (- 58%), delays to starting peptide receptor radionuclide therapy (45.5%), postponed/canceled follow-up examinations (26%), and canceled multidisciplinary teams' activity (20.8%). A low proportion of centers (< 10%) reported having to withdraw systemic anti-tumor medical treatment due to concerns about the pandemic situation, whereas PRRT was withdrawn from no patients., Conclusion: Although the COVID-19 outbreak induced the centers to reduce some important activities in the management of NEN patients, the Italian network was able to provide continuity in care without withdrawing anti-tumor treatment for the majority of patients.

Background: With growing global prevalence of diabetes mellitus, diabetes-related foot disease (DFD) is contributing significantly to disease burden. As more healthcare resources are being dedicated to the management of DFD, service design and delivery is being scrutinised. Through a national survey, this study aimed to investigate the current characteristics of services which treat patients with DFD in Australia., Methods: An online survey was distributed to all 195 Australian members of the Australian and New Zealand Society for Vascular Surgery investigating aspects of DFD management in each member's institution., Results: From the survey, 52 responses were received (26.7%). A multidisciplinary diabetes foot unit (MDFU) was available in more than half of respondent's institutions, most of which were tertiary hospitals. The common components of MDFU were identified as podiatrists, endocrinologists, vascular surgeons and infectious disease physicians. Many respondents identified vascular surgery as being the primary admitting specialty for DFD patients that require hospitalisation (33/52, 63.5%). This finding was consistent even in centres with MDFU clinics. Less than one third of MDFUs had independent admission rights., Conclusions: The present study suggests that many tertiary centres in Australia provide their diabetic foot service in a multidisciplinary environment however their composition and function remain heterogeneous. These findings provide an opportunity to evaluate current practice and, to initiate strategies aimed to improve outcomes of patients with DFD.

Objective: Medical emergency teams (MET) are mostly led by physicians. Some hospitals are currently using nurse practitioners (NP) to lead MET calls. These are no studies comparing clinical outcomes between these two care models. To determine whether NP-led MET calls are associated with lower risk of acute patient deterioration, when compared to intensive care (ICU) registrar (ICUR)-led MET calls., Methods: The composite primary outcome included recurrence of MET call, occurrence of code blue or ICU admission within 24 h. Secondary outcomes were mortality within 24 h of MET call, length of hospital stay, hospital mortality and proportion of patients discharged home. Propensity score matching was used to reduce selection bias from confounding factors between the ICUR and NP group., Results: A total of 1343 MET calls were included (1070 NP, 273 ICUR led). On Univariable analysis, the incidence of the primary outcome was higher in ICUR-led MET calls (26.7% vs. 20.6%, p = 0.03). Of the secondary outcome measures, mortality within 24 h (3.4% vs. 7.7%, p = 0.002) and hospital mortality (12.7% vs. 20.5%, p = 0.001) were higher in ICUR-led MET calls. Propensity score-matched analysis of 263 pairs revealed the composite primary outcome was comparable between both groups, but NP-led group was associated with reduced risk of hospital mortality (OR 0.57, 95% CI 0.35-0.91, p = 0.02) and higher likelihood of discharge home (OR 1.55, 95% CI 1.09-2.2, p = 0.015)., Conclusion: Acute patient deterioration was comparable between ICUR- and NP-led MET calls. NP-led MET calls were associated with lower hospital mortality and higher likelihood of discharge home.

Background: Within the operating rooms (ORs), distractions occur on a regular basis, which affect the surgical workflow and results in the interruption of urgent tasks. This study aimed to observe the occurrence of intraoperative distractions in Tunisian ORs and evaluate associations among distractions, teamwork, workload, and stress., Methods: This observational cross-sectional study was conducted in four different ORs (orthopedic, urology, emergency, and digestive surgery) of Sahloul University Hospital for a period of 3 mo in 2018. Distractions and teamwork were recorded and rated in real time during the intraoperative phase of each case using validated observation sheets. Besides, at the end of each operation, stress and workload of team members were measured., Results: Altogether, 50 cases were observed and 160 participants were included. Distractions happened in 100% of the included operations. Overall, we recorded 933 distractions that occurred once every 3 min, with a mean frequency of M = 18.66 (standard deviation [SD] = 8.24) per case. It is particularly noticeable that procedural distractions occurred significantly higher during teaching cases compared with nonteaching cases (M = 3.85, M = 0.60, respectively, P < 0.001). The mean global teamwork score was M = 3.85 (SD = 0.67), the mean workload score was M = 58.60 (SD = 24.27), and the mean stress score was M = 15.29 (SD = 4.00). Furthermore, a higher stress level among surgeons was associated with distractions related to equipment failures and people entering or exiting the OR (r = 0.206, P < 0.01 and r = 0.137, P < 0.01, respectively). Similarly, nurses reported a higher workload in the presence of distractions related to the work environment in the OR (r = 0.313, P < 0.05)., Conclusions: This study highlighted a serious problem, which often team members seem to ignore or underestimate. Taking our findings into consideration, we recommend the implementation of the Surgical Checklist and preoperative briefings to reduce the number of surgical distractions. Also, a continuous teamwork training should be adopted to ensure that OR staff can avoid or handle distractions when they happen., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Problem: Given the complex interaction among patients, individual providers, health care teams, and the clinical environment, patient safety events with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments (EDs). With low-frequency, high-risk events such as pediatric resuscitations, health care teams working in EDs may not have the clinical opportunity to identify deficiencies, review and reinforce knowledge and skills, and problem solve in authentic clinical conditions. Without creating opportunities to safely practice, hospitals run the risk of having health care teams and environments that are not prepared to provide optimal patient care., Approach: Researchers employed a case series design and used a train-the-trainer model for in situ simulation. They trained health care professionals (instructors) in 3 general, nonacademic EDs in the San Francisco Bay area of California to perform pediatric resuscitation in situ simulations in 2018-2019. In situ simulations occur in the clinical work environment with simulation participants (teams) who are health care professionals taking care of actual patients., Outcomes: Teams made up of physicians, nurses, and ED technicians were evaluated for clinical performance, teamwork, and communication during in situ simulations conducted by instructors at baseline, 6 months, and 12 months. Debriefing after the simulations identified multiple latent safety threats (i.e., unidentified potential safety hazards) that were previously unknown. Each ED's pediatric readiness-its ability to provide emergency care for children-was evaluated at baseline and 12 months., Next Steps: The authors will continue to monitor and examine the impact and sustainability of the pediatric in situ simulation program on pediatric readiness scores and its possible translation to other high-risk clinical settings, as well as explore the relationship between in situ simulations and patient outcomes., (Copyright © 2020 by the Association of American Medical Colleges.)

Background: Surgical options for patients vary with age and comorbidities, advances in medical technology and patients' wishes. This complexity can make it difficult for surgeons to determine appropriate treatment plans independently. At our institution, final decisions regarding treatment for patients are made at multidisciplinary meetings, termed High-Risk Conferences, led by the Patient Safety Committee., Methods: In this retrospective study, we assessed the reasons for convening High-Risk Conferences, the final decisions made and treatment outcomes using conference records and patient medical records for conferences conducted at our institution from April 2010 to March 2018., Results: A total of 410 High-Risk Conferences were conducted for 406 patients during the study period. The department with the most conferences was cardiovascular surgery (24%), and the reasons for convening conferences included the presence of severe comorbidities (51%), highly difficult surgeries (41%) and nonmedical/personal issues (8%). Treatment changes were made for 49 patients (12%), including surgical modifications for 20 patients and surgery cancellation for 29. The most common surgical modification was procedure reduction (16 patients); 4 deaths were reported. Follow-up was available for 21 patients for whom surgery was cancelled, with 11 deaths reported., Conclusions: Given that some change to the treatment plan was made for 12% of the patients discussed at the High-Risk Conferences, we conclude that participants of these conferences did not always agree with the original surgical plan and that the multidisciplinary decision-making process of the conferences served to allow for modifications. Many of the modifications involved reductions in procedures to reflect a more conservative approach, which might have decreased perioperative mortality and the incidence of complications as well as unnecessary surgeries. High-risk patients have complex issues, and it is difficult to verify statistically whether outcomes are associated with changes in course of treatment. Nevertheless, these conferences might be useful from a patient safety perspective and minimize the potential for legal disputes.

Diabetes is one of the most common chronic disorders in emerging adults (15-25 years of age), and the prevalence of both type 1 diabetes (T1D) and type 2 diabetes (T2D) in New Zealand continues to increase in this age group. Tight glycaemic control in both T1D and T2D is well known to reduce diabetic microvascular and macrovascular complications and improve survival. However, in New Zealand and worldwide, emerging adulthood is typically the period of worst glycaemic control in the lifespan due to the high prevalence of psychosocial stressors and increased insulin resistance of puberty and risk-taking behaviours. In addition, the glycaemic control of emerging adults with diabetes in New Zealand often deteriorates due to the loss of support from family and friends from moving regions, the failure of support from paediatric services to extend to emerging adulthood and the loss of public funding for insulin pump therapy as glycaemic targets are no longer met. Given the high prevalence of psychosocial stressors and the loss of support, the International Society for Paediatric and Adolescent Diabetes's (ISPAD's) guidelines recommend that emerging adults with diabetes receive ambulatory care from a dedicated multidisciplinary team consisting of 0.75 full time equivalent (FTE)/100 patients of an endocrinologist, 1-1.25 FTE/100 patients of a diabetes nurse specialist, 0.5 FTE/100 patients of a dietitian, 0.3 FTE/100 patients of a psychologist and 0.3 FTE/100 patients of a social worker or youth worker., Competing Interests: Nil.

Background: Interprofessional primary care (IPC) teams provide comprehensive and coordinated care and are ideally equipped to support those populations most at risk of adverse health outcomes during the COVID-19 pandemic, including older adults, and patients with chronic physical and mental health conditions. There has been little focus on the experiences of healthcare teams and no studies have examined IPC practice during the early phase of the COVID-19 pandemic. The objective of the study was to describe the state of interprofessional health provider practice within IPC teams during the COVID-19 pandemic., Methods: Observational cross-sectional design. A web-based survey was deployed to IPC providers working in team-based primary care clinics in the province of Ontario, Canada. The survey included 26 close-ended and six open-ended questions. Close-ended questions were analyzed using descriptive statistics. Content analysis was used to analyze the open-ended questions., Results: 445 surveys were included in the final analysis. Service delivery shifted from in-person care (77% pre-COVID-19) to telephone (76.5% during the COVID-19 pandemic). Less than half of the respondents (40%) reported receiving any training for virtual delivery. Wait times to access team members were reported to have decreased. There has also been a shift in what IPC providers report as the most commonly seen conditions, with increases in visits related to mental health concerns, acute infections (including COVID-19), social isolation, and resource navigation. Respondents also reported a reduction in healthcare provision for multiple chronic conditions including diabetes, cardiovascular disease, and chronic pain., Conclusions: IPC teams are rapidly shifting their practice to supporting their patients during the pandemic. A surge in mental health issues has been seen and is expected to continue to increase in response to COVID-19. Understanding early experiences can help plan for future pandemic waves.

The coronavirus disease 2019 (COVID-19) pandemic may have affected cancer management. We aimed to evaluate changes in every oncology care pathway essential step, from screening to treatment, during the pandemic. Monthly oncological activity differences between 2019 and 2020 (screening tests, histopathological analyzes, multidisciplinary tumor board meetings (MTBMs), diagnostic announcement procedures (DAPs), and treatments were calculated in two French areas experiencing different pandemic intensity (Reims and Colmar). COVID-19 has had a dramatic impact in terms of screening (-86% to -100%), diagnosis (-39%), and surgical treatment (-30%). This global decrease in all essential oncology care pathway steps contrasted with the relative stability of chemotherapy (-9%) and radiotherapy use (-16%). Outbreak occurred earlier and with more intensity in Colmar but had a comparable impact in both areas regarding MTMBs and DAPs. The current ONCOCARE-COV study is still in progress and with a longer follow-up to analyze postlockdown situation., (© 2020 AlphaMed Press.)

Background: Studying team-based primary care using 100% national outpatient Medicare data is not feasible, due to limitations in the availability of this dataset to researchers., Methods: We assessed whether analyses using different sets of Medicare data can produce results similar to those from analyses using 100% data from an entire state, in identifying primary care teams through social network analysis. First, we used data from 100% Medicare beneficiaries, restricted to those within a primary care services area (PCSA), to identify primary care teams. Second, we used data from a 20% sample of Medicare beneficiaries and defined shared care by 2 providers using 2 different cutoffs for the minimum required number of shared patients, to identify primary care teams., Results: The team practices identified with social network analysis using the 20% sample and a cutoff of 6 patients shared between 2 primary care providers had good agreement with team practices identified using statewide data (F measure: 90.9%). Use of 100% data within a small area geographic boundary, such as PCSAs, had an F measure of 83.4%. The percent of practices identified from these datasets that coincided with practices identified from statewide data were 86% versus 100%, respectively., Conclusions: Depending on specific study purposes, researchers could use either 100% data from Medicare beneficiaries in randomly selected PCSAs, or data from a 20% national sample of Medicare beneficiaries to study team-based primary care in the United States., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Surgical intensive care units (SICU) require complex care from a multi-disciplinary team. Frequent changes in team members can lead to shifting expectations for junior general surgical trainees, which creates a challenging working and learning environment. We aim to identify expectations of junior surgery trainee's medical knowledge and technical/non-technical skills at the start of their SICU rotation. We hypothesize that expectations will not be consistent across SICU stakeholder groups., Methods: Twenty-eight individual semi-structured interviews were conducted with six SICU stakeholder groups at a medium-sized academic hospital. Expectations were identified from interview transcripts. Frequency counts were analyzed., Results: Forty-one expectations were identified. 4 expectations were identified by a majority of interviewees. Most expectations were identified by 7 or fewer interviewees. 23 (53%) expectations were shared by at least one stakeholder group. 2 (8%) expectations were shared by all groups., Conclusions: SICU stakeholder groups identified ten medical knowledge, ten technical skill, and three non-technical skill expectations. Yet, few expectations were shared among the groups. Thus, SICU stakeholder groups have disparate expectations for surgery trainees in our SICU., Competing Interests: Declaration of competing interest The authors have no personal or financial conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Mismanagement of healthcare waste (HCW) during the COVID-19 pandemic can facilitate the transmission of coronavirus. Regarding this problem, there is gap of evidence in Ethiopia, and this study aimed to assess the HCW generation rate and management in Tepi General Hospital, southwest Ethiopia., Methods: Institution-based cross-sectional and case studies were conducted. The total amount of waste generated and its type among various case teams were compared using the Kruskal-Wallis test. Spearman's rank correlation coefficient ( r ) was used to assess the correlation between the total numbers of patients and the total amount of HCW generated. Qualitative data were transcribed verbatim, translated to English, and analyzed with Open Code version 4.02 software, and content analysis was followed., Results: The total mean weight (±SD) of waste generation rate in all service units of the hospital was 492.5 ± 11.5 kg/day. The higher proportion (61.9%) of the total HCW produced was general waste and the remaining (38.1%) was hazardous waste. There was a statistically significant ( X 2  = 82.1, p < 0.001) difference in daily HCW generation rate among different case teams. Similarly, the hospital waste generation amount and total patient flow had a strong positive linear relationship ( r  = 0.7, p =0.032). COVID-19-related medical wastes were not properly handled, segregated, stored, and disposed. There was a scarcity of resources needed to manage HCW, and available resources were utilized poorly. Overall, healthcare wastes were managed as usual (pre-COVID-19)., Conclusion: The mean HCW generation rate in Tepi General Hospital was high. Overall, wastes were mismanaged, and COVID-19-related HCWs have been managed as usual. Availing of important resources and training the concerned bodies should be considered during the crisis of COVID-19., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Besufekad Mekonnen et al.)

Introduction: Multidisciplinary team (MDT) meetings have been the gold standard of cancer care in the UK since the 1990s. We aimed to identify the views of urology cancer MDT members in the UK on improving the functioning of meetings and compare them with those of other specialties to manage the increasing demand on healthcare resources and enhance the care of complex cancer cases., Methods: We analysed data from 2 national surveys distributed by Cancer Research UK focusing on the views of 2,294 and 1,258 MDT members about cancer MDT meetings., Findings: Most breast, colorectal, lung and urology cancer MDT members felt meetings could be improved in the following areas: time for meeting preparation in job plans, streamlining of patients, auditing meeting decisions and prioritising complex cases. Most urology respondents (87%) agreed some patients could be managed outside a full MDT discussion, but this was lower for other specialties (lung 78%, breast 75%, colorectal 64%)., Conclusions: To facilitate decisions on which patients require discussion in an MDT meeting, factors adding to case complexity across all tumour types were identified, including rare tumour type, cognitive impairment and previous treatment failure. This study confirms that urology MDT members are supportive of changing from reviewing all new cancer diagnoses to discussing complex cases but managing others with a more protocolised pathway. The mechanisms for how to do this and how to ensure the safety of patients require further clarification.

Over the past few decades, the effectiveness of antibiotics has been diminished owing to the emergence of antimicrobial resistance resulting from the overuse of antibiotics. Antimicrobial stewardship aims to improve the appropriateness of antibiotic use to reduce antimicrobial resistance and benefit patients. Antimicrobial stewardship requires structural prerequisites for implementing antimicrobial stewardship programs (ASPs), such as the presence of a multidisciplinary antimicrobial stewardship team (AST), to ensure appropriate antimicrobial use at healthcare facilities. However, manpower shortage for ASTs in most Japanese hospitals has resulted in limited implementation of ASPs. Our study provided a directive for promotion of comprehensive ASPs including various outcome measures. Our findings would provide useful benchmarks for hospitals planning to implement ASPs in Japan as well as around the world. This review provides a framework for evaluating the outcome measures and benchmarks of ASPs based on our study.

Background and Objectives: People with kidney failure typically receive KRT in the form of dialysis or transplantation. However, studies have suggested that not all patients with kidney failure are best suited for KRT. Additionally, KRT is costly and not always accessible in resource-restricted settings. Conservative kidney management is an alternate kidney failure therapy that focuses on symptom management, psychologic health, spiritual care, and family and social support. Despite the importance of conservative kidney management in kidney failure care, several barriers exist that affect its uptake and quality., Design, Setting, Participants, & Measurements: The Global Kidney Health Atlas is an ongoing initiative of the International Society of Nephrology that aims to monitor and evaluate the status of global kidney care worldwide. This study reports on findings from the 2018 Global Kidney Health Atlas survey, specifically addressing the availability, accessibility, and quality of conservative kidney management., Results: Respondents from 160 countries completed the survey, and 154 answered questions pertaining to conservative kidney management. Of these, 124 (81%) stated that conservative kidney management was available. Accessibility was low worldwide, particularly in low-income countries. Less than half of countries utilized multidisciplinary teams (46%); utilized shared decision making (32%); or provided psychologic, cultural, or spiritual support (36%). One-quarter provided relevant health care providers with training on conservative kidney management delivery., Conclusions: Overall, conservative kidney management is available in most countries; however, it is not optimally accessible or of the highest quality., (Copyright © 2021 by the American Society of Nephrology.)

Worldwide, Drug-resistant Tuberculosis (DR-TB) remains a big problem; the diagnostic capacity has superseded the clinical management capacity thereby causing ethical challenges. In Sub-Saharan Africa, treatment is either inadequate or lacking and some diagnosed patients are on treatment waiting lists. In Uganda, various health system challenges impeded scale-up of DR-TB care in 2012; only three treatment initiation facilities existed, with only 41 of the estimated 1010 RR-TB/MDR-TB cases enrolled on treatment yet 300 were on the waiting list and there was no DR-TB treatment scale-up plan. To scale up care, the National TB and leprosy Program (NTLP) with partners rolled out a DR-TB mixed model of care. In this paper, we share achievements and outcomes resulting from the implementation of this mixed Model of DR-TB care. Routine NTLP DR-TB program data on treatment initiation site, number of patients enrolled, their demographic characteristics, patient category, disease classification (based on disease site and human immunodeficiency virus (HIV) status), on co-trimoxazole preventive therapy (CPT) and antiretroviral therapy (ART) statuses, culture results, smear results and treatment outcomes (6, 12, and 24 months) from 2012 to 2017 RR-TB/MDR-TB cohorts were collected from all the 15 DR-TB treatment initiation sites and descriptive analysis was done using STATA version 14.2. We presented outcomes as the number of patient backlog cleared, DR-TB initiation sites, RR-TB/DR-TB cumulative patients enrolled, percentage of co-infected patients on the six, twelve interim and 24 months treatment outcomes as per the Uganda NTLP 2016 Programmatic Management of drug-resistant Tuberculosis (PMDT) guidelines (NTLP, 2016). Over the period 2013-2015, the RR-TB/MDR-TB Treatment success rate (TSR) was sustained between 70.1% and 74.1%, a performance that is well above the global TSR average rate of 50%. Additionally, the cure rate increased from 48.8% to 66.8% (P = 0.03). The Uganda DR-TB mixed model of care coupled with early application of continuous improvement approaches, enhanced cohort reviews and use of multi-disciplinary teams allowed for rapid DR-TB program expansion, rapid clearance of patient backlog, attainment of high cumulative enrollment and high treatment success rates. Sustainability of these achievements is needed to further reduce the DR-TB burden in the country. We highly recommend this mixed model of care in settings with similar challenges., Competing Interests: The authors have declared that no competing interests exist.

Background: The coronavirus disease 2019 pandemic has led to the birth of videoconference multidisciplinary teams, which are now commonplace. This remote way of deciding care demands a new set of rules to ensure the quality of the complex decisions that are made for the patient group needing multidisciplinary care. Videoconference multidisciplinary teams bring with them novel forms of distraction that are under-appreciated and can impair decision-making., Method: A practical checklist was generated as applied to videoconference multidisciplinary teams using the principles of human factors awareness and recognition., Results: Some of the strategies that should be adopted to minimise errors arising from human factors are: information technology support, a suitable environment to dial in, a global checklist employed prior to the videoconference, visible participants, avoiding distractions from other sources (e.g. e-mail, mobile phone), a videoconference sign-out and rapid dissemination of the outcomes sheet., Conclusion: This article presents a framework that uses human factors principles applied in this setting, which will contribute to enhanced patient safety, team working and a reduction in medical errors.

Background: Hand-offs in the operating room contribute to poor communication, reduced team function, and may be poorly coordinated with other activities. Conversely, they may represent a missed opportunity for improved communication. We sought to better understand the coordination and impact of intraoperative hand-offs., Methods: We prospectively audio-video (AV) recorded 10 operations and evaluated intraoperative hand-offs. Data collected included percentage of time team members were absent due to breaks, relationships between hand-offs and intraoperative events (incision, surgical counts), and occurrences of simultaneous hand-offs. We also identified announcement that a hand-off had occurred and anchoring, in which team members not involved in the hand-off participated and provided information., Results: Spanning 2919 min of audio-video data, there were 74 hand-offs (range, 4-14 per case) totaling 225.2 min, representing 7.7% of time recorded. Thirty-two (45.1%) hand-offs were interrupted or delayed because of competing activities; eight hand-offs occurred during an instrument or laparotomy pad count. Six cases had simultaneous hand-offs; two cases had two episodes of simultaneous hand-offs. Eight hand-offs included an announcement. Seven included anchoring. Evaluating both temporary and permanent hand-offs, one or more original team members was absent for 40.7% of time recorded and >one team member was absent for 20.5% of time recorded., Conclusions: Intraoperative hand-offs are frequent and not well coordinated with intraoperative events including counts and other hand-offs. Anchoring and announced hand-offs occurred in a small proportion of cases. Future work must focus on optimizing timing, content, and participation in intraoperative hand-offs., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Assigning patients to a call team every fourth day (bolus system) caused the maldistribution of patients among resident teams and required additional faculty effort for overflow patient care. We changed to a continuous daily rotation (drip system) and examined the effect on clinical workload among resident teams, resident education, and faculty utilization., Methods: This is a retrospective study based on the daily records of 7 am team census, the attending physician schedules for a pediatric hospital medicine service with 5 teams, and the measures of resident education, including noon conference attendance, scores on in-service examinations, and duty hour violations. Data from the bolus system (May 2014-June 2015) were compared with the drip system (May 2016-June 2017)., Results: Data from 348 bolus days and 338 drip days were analyzed. There was a decrease in interteam variation from 6.2 to 3.9 patients ( P < 0.001). There were fewer days with the following: large interteam variation (143 to 25, P < 0.001), days with resident teams at or above capacity (26 to 11, P = 0.01), resident teams below a minimum 7 am census (133 to 18, P < 0.001), and days when additional faculty were pulled for clinical care (61 to 9, P < 0.001). Resident noon conference attendance was unchanged and there was no adverse effect on examination scores or duty hour violations., Conclusions: Changing from a bolus to a drip model for admissions to inpatient teams resulted in a more even distribution of the workload and a more efficient use of physician resources without negatively affecting resident education.