IntroductionIndividuals with co-occurring mental and physical health issues have worse health outcomes in both domains. Integration improves outcomes and aligns with patient preference, but health ...services tend to be siloed. The Mental Health in Medicine Clinic (MHiM) supports patients receiving inpatient or outpatient medical or surgical care at a tertiary academic hospital in Toronto, Canada. The predominantly virtual clinic has an interdisciplinary team offering services via stepped care, matching patient need with service intensity. Measurement-based care (MBC), the systematic evaluation of patient reported outcomes, was not initially used routinely in the clinic, but its implementation may improve treatment decision-making and may be useful in allocating patients within a stepped care model.Objectives1) To describe the stepped care model, referral patterns, diagnoses, and level of care provided since implementation of stepped care. 2) To conduct a quality improvement initiative to implement MBC in the clinic, with a goal of 50% of patients completing at the time of first assessment and prior to discharge from the clinic.MethodsWe reviewed the electronic medical record for referral source, diagnoses, and level of stepped care within the clinic. We conducted semi-structured interviews with stakeholders (clinicians, administrative staff, patients) to explore barriers to implementation of MBC. Interviews were analyzed for themes around barriers and facilitators to MBC. Plan, Do, Study, Act cycles were carried out around change concepts informed by stakeholder interviews and relevant literature.ResultsThe MHiM clinic began operations in August 2020. The clinic operated on a physician-only model until March 2022 and then shifted to a stepped care model with an interdisciplinary team. The most frequent referral sources were internal medicine, COVID19 clinics, consultation-liaison psychiatry, red blood cell disorders clinic and cardiology. Since the implementation of stepped care, 250 referrals were assessed. 58% of new referrals were assessed by the psychiatrist, 42% were managed by the NP, and 25% consulted with the social worker. Referrals consisted of trauma and stress-related disorders (32%), depression (21%) or anxiety disorders (20%). Personality, substance use, and psychotic disorders accounted for less than 10% of referrals combined. Some patients did not have any diagnosis (6%). Results from the quality improvement initiative to implement MBC will also be presented.ConclusionsThe MHiM clinic provides an integrated care pathway addressing comorbid mental and physical health conditions. We describe a novel stepped care model and the implementation of MBC. Future directions include ongoing quality improvement of MBC and its integration within the clinic to assess and re-assess service intensity.Disclosure of InterestNone Declared
Background: Existing care pathways for complex spine surgery include mitigation of modifiable patient factors, multidisciplinary team determination of appropriateness, and 2 attending surgeries. ...Opportunities for, and benefit of, effective communication and team dynamics are areas that have received less attention, despite demonstrated effectiveness in other surgical specialties. We report our early experience in developing, initiating and utilizing a comprehensive perioperative communication tool for complex spine surgeries. Methods: A comprehensive spinespecific communication tool was developed combining existing local tools with published and validated care pathways using a Delphi process that included operating and recovery room technicians and nursing staff, anesthesiology, respiratory therapists, radiographers, neuromonitoring and cell-salvage technicians, residents, fellows and spine surgeons. Multiple plan-do-study-act (PDSA) cycles resulted in the current tool, consisting of a standardized surgical time-out in attestation format, a whiteboard to facilitate intraoperative communication and personnel handovers and a postoperative recovery room handover tool. Pre-, peri- and post-implementation surveys were distributed to all operating room personnel after each PDSA cycle. Once established, intraoperative and post-operative adverse events (using SAVES), length of stay and patientreported outcome measures will be compared with a matched historical cohort to examine the effectiveness of the tool. Results: Before development of the tool, poor communication, role uncertainty and lack of continuity were highlighted concerns in multiple staff surveys. Our initial pilot study consisted of 14 complex deformity surgeries, of which 3 were 2-day cases. Each case served as a separate PDSA cycle, allowing adaptation and refinement of the communication tool. Improvement in teamwork was reported by 94%, and a decrease in unnecessary interruptions and duplications was reported at a rate of 89% and 78%, respectively. Improvement in communication at handover and in overall operating room team dynamics, as well as role identification, were cited as primary benefits of the communication tool in qualitative feedback. Conclusion: With engagement of a multidisciplinary team, a comprehensive complex spine care communication tool can be successfully implemented at a tertiary care facility, improving perioperative communication, handover efficiency, role assumption and team dynamics.
The opioid pandemic, and particularly injection drug use, has led to an increase in cases of tricuspid valve infective endocarditis. Indications for valve surgery in right-sided infective ...endocarditis are not well-defined. Percutaneous mechanical aspiration is considered an alternative in patients at high risk for re-infection of a prosthetic valve but lacks robust outcomes data.
This retrospective analysis compares the primary outcome of death within 1 year for patients with isolated tricuspid valve infective endocarditis treated with medical therapy alone vs percutaneous mechanical aspiration or valve surgery.
The authors performed a retrospective cohort study of patients with isolated tricuspid valve infective endocarditis over a 10-year period. Medical record review was performed to collect demographic-and outcomes-related data. The association between treatment group and outcomes was assessed using Cox proportional hazard regression with inverse probability of treatment weighting.
Between January 1, 2009, and December 31, 2018, 215 patients with isolated tricuspid valve infective endocarditis and surgical indications were identified. One hundred patients (46.5%) were managed medically, 49 (22.8%) were managed surgically, and 66 (30.7%) underwent percutaneous mechanical aspiration. There was no significant difference in 1-year mortality between the 3 treatment groups (P = .15). Vegetation size > 2.0 cm was associated with increased 1-year mortality (hazard ratio 3.01; P = .03). Addiction medicine consultation was associated with decreased 1-year mortality (hazard ratio 0.117; P = .0008).
The study highlights that surgery or percutaneous mechanical aspiration in addition to medical therapy does not improve 1-year mortality in patients with isolated tricuspid valve infective endocarditis. Addiction medicine consultation was associated with decreased 1-year mortality in patients with injection drug use-associated isolated tricuspid valve infective endocarditis.
IntroductionEndoscopic resection strategies are becoming increasingly complex for colorectal polyps. Decision making relies significantly on post procedure captured endoscopic images presented at ...multidisciplinary team (MDT) meetings, however image quality assessment has not been reported in the literature. This study assessed the quality of image capture in a tertiary centre, complex polyp MDT, and evaluated impact on decision making.MethodsPolyp MDT referrals were reviewed retrospectively over a 6-month period at a single academic centre. Those requiring interpretation of endoscopic imaging of polyps were assessed by two members of the MDT, after initially establishing consensus on a minimum acceptable standard for image quality criteria.ResultsA total of 100 polyp referrals were identified. The reasons for referrals were polypectomy planning (77%) or post resection histology (23%). The majority of referrals were made by interventional endoscopists (38%), followed by trainees (31%), gastroenterology consultants (18%), nurse endoscopists (8%) and surgical consultants (5%). The predominant polyp location was rectum (33%) and sigmoid (21%), followed by ascending colon (15%), caecum (11%), rectosigmoid (8%), descending (6%), transverse (5%) and anal verge (1%). The majority of polyps were greater than 20mm (53% >20mm, 36% 10–19mm, 7%<10mm, 4% unknown). Paris classification was not specified in 21% of referrals, and 19% had no documented optical diagnosis. In 31% of cases, image quality was deemed suboptimal and negatively impacted on resection strategy decision making at the MDT. Surgical endoscopists and trainees were the most likely to make a referral with suboptimal image quality; 60% of surgical endoscopist referrals and 37% of trainee referrals had suboptimal image quality and negatively impacted on MDT decision making.ConclusionsTo our knowledge, this is the first reported assessment of image quality at a complex polyp MDT. A significant proportion of images were deemed suboptimal and negatively impacted on resection strategy decision making. Quality improvement initiatives are needed to promote high quality image capture standards, particularly for complex polyps. Initiatives could include dedicated training and competency assessments. Emerging endoscopic video recording platforms and AI assisted image capture software could offer novel solutions.
PDF
