Safe preoperative regional nerve blocks

BackgroundProcedural time-outs and checklists are proven to be an effective means of improving teamwork and preventing wrong-sided procedures. The main objective of this study was to ensure that all regional nerve blocks being performed in the preoperative area at our hospital were executed with a proper time-out. The goal of this project was to increase integration of a safe preoperative block process including a time-out checklist to ensure; complete consents, correct patient and laterality were marked prior to each procedure. We focused on recognising events that took place before, during and after the nerve block including non-compliance with the checklist and deviations from protocol.MethodsA safe preoperative block process current and future state flowchart, revised time-out checklist and action/implementation plan as part of our Plan–Do–Study–Act model was constructed using a multidisciplinary approach. Pre-implementation and post- implementation data were collected by medical students acting anonymously via direct observation noting the presence of an anaesthesiologist, resident, nurse, time-out for procedure, checklist completed and procedure start and sedation time representing a complete time-out.ResultsThe direct observations in the pre-implementation group showed a 20% (3/15) compliance with a correct time-out. The direct observations in the post implementation group showed 85% (12/14) compliance. This revealed a 65% increase in all portions of the time-out checklist completed. Comparative analysis confirmed decrease in non-compliance and deviations from protocol as displayed by 65% increase in all portions of time-out checklist completed.ConclusionWe aimed to improve safety, communication and compliance for preoperative nerve blocks through development and implementation of a safe preoperative block process using a multidisciplinary model. We conclude that creation of a safe nerve block was achieved by integration of a preoperative nerve block process which included increased compliance to the time-out checklist, verifying patients and laterality with marking of patient prior to each procedure, identifying proper consents were completed and ensuring each regional nerve block was executed with a proper time-out.

Extending Evaluation Capacity Building Theory to Improvement Science Networks

Evaluation practices are continuing to evolve, particularly in those areas related to formative, participatory, and improvement approaches. Improvement science is one of the evaluative practices. Its strength is that it seeks to embrace stakeholders’ and frontline workers’ knowledge and experience, who are often tasked with leading improvement activities in their organizations. However, very little guidance exists on how to develop crucial improvement capacity. Evaluation capacity building literature has the potential to fill this gap. This multiple methods case study follows a networked improvement community’s first year in a public education setting as network leaders sought to build capacity by incorporating Preskill and Boyle’s multidisciplinary model as its guiding framework. The purpose of this study was to better understand how to build improvement science capacity, along with what facilitates implementation and beneficial learnings. This article ends by reconceptualizing and extending Preskill and Boyle’s model to improvement science networks.

838. A Multidisciplinary Approach to the Management of Renal Disease in Patients with HIV

Background Chronic kidney disease (CKD) remains an important complication of HIV infection, with up to 30% of people with HIV (PWH) having abnormal renal function. Those with HIV and CKD are reported to have higher mortality than those with either alone. As survival of PWH continues to improve with antiretroviral therapy, additional risk factors for CKD become more prevalent with advancing age. Optimizing management of renal disease in this population to reduce mortality and progression to ESRD has become a more pressing need. Our study describes the implementation of a multidisciplinary HIV/nephrology clinic nested within a Ryan White HIV/AIDS Program-funded clinic on the progression of renal disease in PWH in New Orleans. Methods Clinic patients with HIV with at least CKD stage 3 (excluding those with end-stage renal disease) or significant proteinuria were eligible to be referred. Both an HIV primary care provider and a nephrologist evaluated patients at their initial visit, and the subspecialists jointly developed treatment plans. Patients included in the initial analysis were evaluated between January and May 2021. Baseline renal function and proteinuria were obtained, as well as additional studies as appropriate. Results A total of 1,968 patients were seen in the HIV clinic during the 18 months prior to the referral period. 305 (15.5%) had an ICD-10 diagnosis code for either CKD or proteinuria. During January – May 2021, 15 patients were referred and 13 evaluated in the multidisciplinary clinic, including 10 men and 3 women. Patients were seen an average of 1.3 times during this time. 8 patients were African-American, and 4 where white. Median age was 59. Median creatinine clearance at baseline was 45 mL/minute. Among those with proteinuria, median proteinuria was 891 mg/g. 8 patients had a diagnosis of hypertension, while 2 had diabetes mellitus. Initial data show a mean improvement in creatinine clearance of 4.2 mL/minute over a mean of 105 days of observation in those with repeat measurements. Conclusion There continues to be a high prevalence of CKD in PWH in the era of ART. Given the natural history of kidney disease, an improvement in creatinine clearance is promising. Aggressive co-management of HIV and CKD using a multidisciplinary model may limit progression of CKD and mortality. Disclosures Yussef Bennani, MD, MPH, Gilead Sciences (Scientific Research Study Investigator)ViiV Healthcare (Scientific Research Study Investigator)

Accelerated Early Progression of Amyotrophic Lateral Sclerosis over the COVID-19 Pandemic

During the COVID-19 pandemic and the related lockdowns, outpatient follow-up visits for patients with chronic neurological diseases have been suspended. Managing people affected by amyotrophic lateral sclerosis (ALS) has become highly complicated, leaving patients without the standard multidisciplinary follow-up. This study aimed to analyze the impact of the COVID-19 lockdown on ALS disease progression. We compared the clinical data and progression in the first year following diagnosis for patients who received ALS diagnosis during 2020 (G20, N = 34), comparing it with a group of diagnosed in 2018 (G18, N = 31). Both groups received a comparable multidisciplinary model of care in our Tertiary Expert ALS Centre, Novara, Italy. The monthly rate of ALSFRS-R decline during the lockdown was significantly increased in G20 compared to G18 (1.52 ± 2.69 vs. 0.76 ± 0.56; p-value: 0.005). In G20, 47% required non-invasive ventilation (vs. 32% of G18). Similarly, in G20, 35% of patients died vs. 19% of patients in G18 (p-value: 0.01). All results were corrected for gender, age, site of onset, and diagnostic delay. Several factors can be implicated in making ALS more severe, with a faster progression, such as reduced medical evaluations and the possibility of therapeutic changes, social isolation, and rehabilitation therapy suspension.

Cellular, Hormonal, and Behavioral Responses of the Holothuroid Cucumaria frondosa to Environmental Stressors

Holothuroids (sea cucumbers) are one of the most ubiquitous groups of benthic animals found across diverse marine ecosystems. As echinoderms, they also occupy an important place in the evolutionary hierarchy, sitting close to vertebrates in the deuterostome clade, making them valuable multidisciplinary model organisms. Apart from being ecologically and phylogenetically important, many species are commercially exploited for luxury seafood markets. With the global rise of aquaculture and fisheries, management and protection of these valuable species relies on a better understanding of how their immune systems respond to environmental and anthropogenic stressors. Here, the cellular, hormonal and behavioral indicators of stress in the North Atlantic sea cucumber Cucumaria frondosa were examined. The immediate and carry-over (post recovery) effects of a 1-hour exposure to low salinities or to emersion (at two temperatures) highlighted that morphoplasticity in C. frondosa was accompanied by shifts in all monitored indicators. From baseline levels measured in controls, densities of free coelomocytes increased, showing successions of specific cell types and subsequent coelomocyte aggregations, combined with a rise in cortisol levels. These responses mirrored increased fluctuations in cloacal opening rates, decreased force of attachment to the substrate, and enhanced movements and active buoyancy adjustment with increasingly severe stressors. The findings suggest that many systems of sea cucumbers are impacted by stresses that can be associated with harvesting and handling methods, with likely implications for the quality of the processed products. Gaining a deeper understanding of immune and hormonal responses of sea cucumbers is not only of broad ecological and evolutionary value, but also helpful for the development of sustainable fisheries and aquaculture practices, and conservation programs.

The Way of Improvement of Quality of Life of Older Persons as Users and Maintainers of Technical Means

In the article the way of improvement quality of life as users and maintainers of technical means is presented. It is assumed that it is necessary to keep the fundamental of sustainable development. Therefore the application of the scheme of the process of satisfying needs is shown. It helps establish the activities necessary to achieve this goal and enables to plan required information resources. In the range of exploitation and design tasks the application of original strategy of exploitation by older persons was proposed. This strategy uses 6R method which in the future will be supplemented on elements commonly executed strategies and policies of exploitation. Decision making in accordance with proposed strategy will be possible by performing calculations and simulation with the use of multidisciplinary model, whose conception was indicated in the article and which uses matrix of assessment of the quality of life.

Eating Disorders and the Rorschach

In this article we review research on eating disorders with the Rorschach. In this field there are two main lines of research involving two specific methodologies: the Comprehensive System and the French school. We present the main results of the different studies separately and then comment on some similarities and differences in the findings. We find that the results of these studies are complementary on certain aspects of functioning found in anorexia nervosa as compared with other categories of eating disorders. Both sets of studies underline the self-centeredness of anorexic patients with their difficulty in communicating their feelings and thoughts. In both types of study, treatment is understood as relying on an integrative and multidisciplinary model that seeks to modify the eating behaviors and to improve ego functions in order to moderate the patient’s distress. In addition, both types of research show that secure attachment would be the first priority for the therapist in psychological treatment, which should increase the patient’s confidence in others. They also both stress the importance of the restoration of self-esteem and a sense of identity through the support offered by the relationship to the therapist.