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1.  Reducing Referral-to-Treatment Waiting Times in Cancer Patients Using a Multidisciplinary Database 
INTRODUCTION
Modern delivery of cancer care through patient-centred multidisciplinary teams (MDT) has improved survival. This approach, however, requires effective on-going co-ordination between multiple specialties and resources and can present formidable organisational challenges. The aim of this study was to improve the efficiency of the MDT process for head and neck cancer.
PATIENTS AND METHODS
A systems analysis of the MDT process was undertaken to identify bottlenecks delaying treatment planning. The MDT process was then audited. A revised process was developed and an Intranet-based data management solution was designed and implemented. The MDT process was re-evaluated to complete the audit cycle.
RESULTS
We designed and implemented a trust-wide menu-driven database with interfaces for registering and tracking patients, and automated worklists for pathology and radiology. We audited our MDT for 11 and 10 weeks before and following the introduction of the database, with 226 and 187 patients being discussed during each period. The database significantly improved cross-specialtity co-ordination, leading to a highly significant reduction in the number of patients whose treatment planning was delayed due to unavailability of adjunctive investigations (P < 0.001). This improved the overall efficiency of the MDT by 60%.
CONCLUSIONS
The NHS Cancer Plan aspires to reduce the referral-to-treatment time to 1 month. We have shown that a simple, trust-wide database reduces treatment planning delays in a sizeable proportion of head and neck cancer patients with minimal resource implications. This approach could easily be applied in other MDT meetings.
doi:10.1308/003588407X155455
PMCID: PMC1964554  PMID: 17346401
Referral-to-treatment; Waiting times; Cancer patients; Multidisciplinary teams
2.  Using computerised decision support to improve compliance of cancer multidisciplinary meetings with evidence-based guidance 
BMJ Open  2012;2(3):e000439.
Objectives
The cancer multidisciplinary team (MDT) meeting (MDM) is regarded as the best platform to reduce unwarranted variation in cancer care through evidence-compliant management. However, MDMs are often overburdened with many different agendas and hence struggle to achieve their full potential. The authors developed an interactive clinical decision support system called MATE (Multidisciplinary meeting Assistant and Treatment sElector) to facilitate explicit evidence-based decision making in the breast MDMs.
Design
Audit study and a questionnaire survey.
Setting
Breast multidisciplinary unit in a large secondary care teaching hospital.
Participants
All members of the breast MDT at the Royal Free Hospital, London, were consulted during the process of MATE development and implementation. The emphasis was on acknowledging the clinical needs and practical constraints of the MDT and fitting the system around the team's workflow rather than the other way around. Delegates, who attended MATE workshop at the England Cancer Networks' Development Programme conference in March 2010, participated in the questionnaire survey.
Outcome measures
The measures included evidence-compliant care, measured by adherence to clinical practice guidelines, and promoting research, measured by the patient identification rate for ongoing clinical trials.
Results
MATE identified 61% more patients who were potentially eligible for recruitment into clinical trials than the MDT, and MATE recommendations demonstrated better concordance with clinical practice guideline than MDT recommendations (97% of MATE vs 93.2% of MDT; N=984). MATE is in routine use in breast MDMs at the Royal Free Hospital, London, and wider evaluations are being considered.
Conclusions
Sophisticated decision support systems can enhance the conduct of MDMs in a way that is acceptable to and valued by the clinical team. Further rigorous evaluations are required to examine cost-effectiveness and measure the impact on patient outcomes. The decision support technology used in MATE is generic and if found useful can be applied across medicine.
Article summary
Article focus
How to improve the conduct of a cancer MDT and standardise decision making in accordance with best evidence.
Development and implementation of a novel clinical decision support (CDS) platform for breast cancer MDT.
This study evaluates (1) the concordance between the CDS suggestions and MDT recommendations and (2) the identification rate of potentially eligible patients for recruiting into the ongoing research trials, by the MDT and the CDS. A separate questionnaire survey was conducted at the national workshop at the Cancer Networks' Development Programme to get an estimate of acceptability of such MDT decision support systems by the cancer networks.
Key messages
An advanced CDS platform could significantly improve the conduct of cancer MDMs.
Further robust evaluations are necessary.
Strengths and limitations of this study
We share our experience of developing an advanced decision support system and implementing it in a complex clinical environment of cancer MDT, which was subsequently adopted as a breast MDMs management tool.
The results reported here, however encouraging, are at this point indicative of the potential benefits but not yet conclusive. They should be treated with caution until further rigorous evaluations confirm the effectiveness and generalisability of the CDS system.
doi:10.1136/bmjopen-2011-000439
PMCID: PMC3383983  PMID: 22734113
3.  What is a virtual multidisciplinary team (vMDT)? 
British Journal of Cancer  2013;108(12):2433-2441.
Background:
Multidisciplinary team meetings (MDTs), also known as tumour boards or multidisciplinary case conferences, are an integral component of contemporary cancer care. There are logistical problems with setting up and maintaining participation in these meetings. An ill-defined concept, the virtual MDT (vMDT), has arisen in response to these difficulties. We have, in order to provide clarity and to generate discussion, attempted to define the concept of the vMDT, outline its advantages and disadvantages, and consider some of the practical aspects involved in setting up a virtual MDT.
Methods:
This is an unstructured review of published evidence and personal experience relating to virtual teams in general, and to MDTs in particular.
Results:
We have devised a simple taxonomy for MDTs, discussed some of the practicalities involved in setting up a vMDT, and described some of the potential advantages and disadvantages associated with vMDTs.
Conclusion:
The vMDT may be useful for discussions concerning rare or unusual tumours, or for helping guide the assessment and management of patients with uncommon complications related to treatment. However, the vMDT is a niche concept and is currently unlikely to replace the more traditional face-to-face MDT in the management of common tumours at specific sites.
doi:10.1038/bjc.2013.231
PMCID: PMC3694234  PMID: 23756866
multidisciplinary teams; virtual teams; tumour board; multidisciplinary case conference; information technology; telemedicine
4.  Developing a Multidisciplinary Team for Disorders of Sex Development: Planning, Implementation, and Operation Tools for Care Providers 
Advances in Urology  2012;2012:604135.
In the treatment of patients with disorders of sex development (DSD), multidisciplinary teams (MDTs) represent a new standard of care. While DSDs are too complex for care to be delivered effectively without specialized team management, these conditions are often considered to be too rare for their medical management to be a hospital priority. Many specialists involved in DSD care want to create a clinic or team, but there is no available guidance that bridges the gap between a group of like-minded DSD providers who want to improve care and the formation of a functional MDT. This is an important dilemma, and one with serious implications for the future of DSD care. If a network of multidisciplinary DSD teams is to be a reality, those directly involved in DSD care must be given the necessary program planning and team implementation tools. This paper offers a protocol and set of tools to meet this need. We present a 6-step process to team formation, and a sample set of tools that can be used to guide, develop, and evaluate a team throughout the course of its operation.
doi:10.1155/2012/604135
PMCID: PMC3389653  PMID: 22792098
5.  The Central Urology Multidisciplinary Team – Is it Time to Change the Referral Criteria? An Audit of Practice in a District General Hospital in London 
INTRODUCTION
All cancer patients are discussed in multidisciplinary team meetings (MDTs). Certain patients are referred to the Central MDT based on specific national criteria. We wanted to see whether the Central MDT aided in the decision-making process above that of the Local MDT alone.
PATIENTS AND METHODS
All MDT forms (local and central) for 2007 were retrospectively reviewed.
RESULTS
A total of 217 patients were reviewed at the Local MDT. Of these 217 cases, 102 (47.0%) cases were referred to the Central MDT and 15 of the 102 (14.7%) cases were awaiting investigations at the time of the Local MDT and were, therefore, excluded. For the prostate cancer cases (n = 67), the Central MDT did not change outright the Local MDT decision in any case, but in 6 of 67 (9.0%), advised/excluded patients from clinical trials. For bladder cancer cases (n = 19), 4 of 19 (21.0%) patients had their management changed by the Central MDT. The one kidney cancer case had its Local MDT decision changed by the Central MDT.
CONCLUSIONS
This audit suggests that the Central MDT plays a useful role in the decision-making process for bladder and kidney cancers, and helps determine eligibility for clinical trials in metastatic prostate cancer patients. Its value over the Local MDT alone in the decision-making process for non-metastatic prostate cancer is questionable.
doi:10.1308/003588409X12486167521190
PMCID: PMC2966256  PMID: 19785943
Multidisciplinary team; MDT; Audit; Arology
6.  Benefits of multidisciplinary teamwork in the management of breast cancer 
The widespread introduction of multidisciplinary team (MDT)-work for breast cancer management has in part evolved due to the increasing complexity of diagnostic and treatment decision-making. An MDT approach aims to bring together the range of specialists required to discuss and agree treatment recommendations and ongoing management for individual patients. MDTs are resource-intensive yet we lack strong (randomized controlled trial) evidence of their effectiveness. Clinical consensus is generally favorable on the benefits of effective specialist MDT-work. Many studies have shown the benefits of receiving treatment from a specialist center, and evidence continues to accrue from comparative studies of clinical benefits of an MDT approach, including improved survival. Patients’ views of the MDT model of decision-making (and in particular its impact on involvement in decisions about their care) have been under-researched. Barriers to effective teamwork and poor decision-making include excessive caseload, low attendance at meetings, lack of leadership, poor communication, role ambiguity, and failure to consider patients’ holistic needs. Breast cancer nurses have a key role in relation to assessing holistic needs, and their specialist contribution has also been associated with improved patient experience and quality of life. This paper examines the evidence for the benefits of MDT-work, in particular for breast cancer. Evidence is considered within a context of growing cancer incidence at a time of increased financial restraint, and it may now be important to reevaluate the structure and models of MDT-work to ensure that MDTs are an efficient use of resources.
doi:10.2147/BCTT.S35581
PMCID: PMC3929250  PMID: 24648761
interdisciplinary teams; interprofessional interactions; multidisciplinary collaboration; teams; teamwork
7.  Protocol-driven care in the intensive care unit: a tool for quality 
Critical Care  2001;5(6):283-285.
Advances in organization and patient management in the intensive care unit (ICU) have led to reductions in the morbidity and mortality suffered by critically ill patients. Two such advances include multidisciplinary teams (MDTs) and the development of clinical protocols. The use of protocols and MDTs does not necessarily guarantee instant improvement in the quality of care, but it does offer useful tools for the pursuit of such objectives. As ICU physicians increasingly assume leadership roles in the pursuit of higher quality ICU care, their knowledge and skills in the discipline of quality improvement will become essential.
doi:10.1186/cc1048
PMCID: PMC137367  PMID: 11737905
clinical protocols; critical care; mechanical ventilation; multidisciplinary team; quality of health care
8.  Cancer Multidisciplinary Team Meetings: Evidence, Challenges, and the Role of Clinical Decision Support Technology 
Multidisciplinary team (MDT) model in cancer care was introduced and endorsed to ensure that care delivery is consistent with the best available evidence. Over the last few years, regular MDT meetings have become a standard practice in oncology and gained the status of the key decision-making forum for patient management. Despite the fact that cancer MDT meetings are well accepted by clinicians, concerns are raised over the paucity of good-quality evidence on their overall impact. There are also concerns over lack of the appropriate support for this important but overburdened decision-making platform. The growing acceptance by clinical community of the health information technology in recent years has created new opportunities and possibilities of using advanced clinical decision support (CDS) systems to realise full potential of cancer MDT meetings. In this paper, we present targeted summary of the available evidence on the impact of cancer MDT meetings, discuss the reported challenges, and explore the role that a CDS technology could play in addressing some of these challenges.
doi:10.4061/2011/831605
PMCID: PMC3262556  PMID: 22295234
9.  Multidisciplinary management of hepatocellular carcinoma: a model for therapy 
A multidisciplinary model is a useful approach in the management of hepatocellular carcinoma (HCC) to coordinate, individualize, and optimize care. The HCC Multidisciplinary Team (MDT) at Temple University Hospital was established in 2008 and comprises hepatologists, interventional radiologists, transplant surgeons, oncologists, residents, midlevel providers, and support staff. Patients may be enrolled by referral from (1) oncologists at Temple, (2) the hepatitis screening clinic recently established at Temple and staffed by hepatology residents, or (3) community practices. MDT conferences are held weekly, during which cases are discussed (based on medical history, interpretation of images, and laboratory analyses) and treatment plans are formulated. The Temple treatment algorithm follows current standards of care, guided by tumor volume and morphology, but the novel multidisciplinary interaction challenges members to tailor therapy to achieve the best possible outcomes. Patients with a solitary lesion ≤ 2 cm may receive no treatment until eligible for transplantation or locoregional therapy or resection, with imaging every 3 to 6 months to monitor tumor progression. In patients with tumors > 2 cm and ≤ 5 cm, microwave ablation therapy is used if lesions are discrete and accessible. Conventional transarterial chemoembolization (TACE) or drug-eluting bead TACE (DEB-TACE) or yttrium-90 microspheres are utilized in multifocal disease. Patients with lesions > 5 cm are candidates for TACE for downstaging the tumor. Sorafenib is typically reserved for unresectable lesions between 2 cm and 5 cm. Frequently, we administer sorafenib continuously and in combination with DEB-TACE. In our experience, sorafenib does not produce effects on the tumor vasculature or blood flow that would impair the efficacy of DEB-TACE. The literature documents improved outcomes in HCC and other cancers associated with the introduction of multidisciplinary care. The role and organization of the MDT is influenced by team culture, expertise, and process, as well as institutional and larger environmental contexts.
doi:10.2147/JMDH.S41206
PMCID: PMC3656893  PMID: 23690690
HCC; coordinated care; interdisciplinary; transplant
10.  Are multidisciplinary teams in secondary care cost-effective? A systematic review of the literature 
Objective
To investigate the cost effectiveness of management of patients within the context of a multidisciplinary team (MDT) meeting in cancer and non-cancer teams in secondary care.
Design
Systematic review.
Data sources
EMBASE, MEDLINE, NHS EED, CINAHL, EconLit, Cochrane Library, and NHS HMIC.
Eligibility criteria for selecting studies
Randomised controlled trials (RCTs), cohort, case–control, before and after and cross-sectional study designs including an economic evaluation of management decisions made in any disease in secondary care within the context of an MDT meeting.
Data extraction
Two independent reviewers extracted data and assessed methodological quality using the Consensus on Health Economic Criteria (CHEC-list). MDTs were defined by evidence of two characteristics: decision making requiring a minimum of two disciplines; and regular meetings to discuss diagnosis, treatment and/or patient management, occurring at a physical location or by teleconferencing. Studies that reported on the costs of administering, preparing for, and attending MDT meetings and/or the subsequent direct medical costs of care, non-medical costs, or indirect costs, and any health outcomes that were relevant to the disease being investigated were included and classified as cancer or non-cancer MDTs.
Results
Fifteen studies (11 RCTs in non-cancer care, 2 cohort studies in cancer and non-cancer care, and 2 before and after studies in cancer and non cancer care) were identified, all with a high risk of bias. Twelve papers reported the frequency of meetings which varied from daily to three monthly and all reported the number of disciplines included (mean 5, range 2 to 9). The results from all studies showed mixed effects; a high degree of heterogeneity prevented a meta-analysis of findings; and none of the studies reported how the potential savings of MDT working may offset the costs of administering, preparing for, and attending MDT meetings.
Conclusions
Current evidence is insufficient to determine whether MDT working is cost-effective or not in secondary care. Further studies aimed at understanding the key aspects of MDT working that lead to cost-effective cancer and non-cancer care are required.
doi:10.1186/1478-7547-11-7
PMCID: PMC3623820  PMID: 23557141
Multidisciplinary teams; Cost-effective; Secondary care
11.  MRI directed multidisciplinary team preoperative treatment strategy: the way to eliminate positive circumferential margins? 
British Journal of Cancer  2006;94(3):351-357.
Histopathological audit of positive circumferential resection margins (CRMs) can be used as a surrogate measure of the success of rectal cancer treatment. We audited CRM involvement in rectal cancer patients and the impact of the multidisciplinary team (MDT) on implementing a magnetic resonance imaging (MRI)-based preoperative treatment strategy. Data were collected on all newly diagnosed rectal cancer patients treated in our network between January 1999 and December 2002. Data were analysed for MRI prediction and histopathological assessment of CRM together with the MDT meeting treatment decisions. The CRM+ve rate of those discussed at MDT vs those not discussed were compared. We re-audited the CRM+ve rates 1 year after introducing a policy of mandatory preoperative MRI-based MDT discussion. Of the 298 patients diagnosed with rectal cancer, 39 (13%) were deemed palliative, 178 underwent surgery alone and 81 underwent neoadjuvant therapy. Of these, 62 out of 178 patients underwent surgery alone without MRI-based MDT discussion resulting in positive CRM in 16 cases (26%) as compared to 1 out of 116 (1%) in those patients with MDT discussion of MRI. Overall CRM+ve rate in all nonpalliative patients with or without MDT discussion was 12.5% (32 out of 256), significantly lower than the <20% rate (P<0.001) quoted in national guidelines. Re-audit in 98 consecutive patients following a change of policy produced a lower CRM+ve rate of 3% (1 out of 37) for all surgery alone patients and an overall CRM+ve rate of 7% (5 out of 70). In conclusion, MDT discussion of MRI and implementation of a preoperative treatment strategy results in significantly reduced positive CRM in rectal cancer patients.
doi:10.1038/sj.bjc.6602947
PMCID: PMC2361145  PMID: 16465171
magnetic resonance imaging; rectal cancer; chemoradiotherapy; multidisciplinary team; circumferential resection margin
12.  Implementation of neuro-oncology service reconfiguration in accordance with NICE guidance provides enhanced clinical care for patients with glioblastoma multiforme 
British Journal of Cancer  2011;104(12):1810-1815.
Background:
Brain tumours account for <2% of all primary neoplasms but are responsible for 7% of the years of life lost from cancer before age 70 years. The latest survival trends for patients with CNS malignancies have remained largely static. The objective of this study was to evaluate the change in practice as a result of implementing the Improving Outcomes Guidance from the UK National Institute for Health and Clinical Excellence (NICE).
Methods:
Patients were identified from the local cancer registry and hospital databases. We compared time from diagnosis to treatment, proportion of patients discussed at multidisciplinary team (MDT) meetings, treatment received, length of inpatient stay and survival. Inpatient and imaging costs were also estimated.
Results:
Service reconfiguration and implementation of NICE guidance resulted in significantly more patients being discussed by the MDT—increased from 66 to 87%, reduced emergency admission in favour of elective surgery, reduced median hospital stay from 8 to 4.5 days, increased use of post-operative MRI from 17 to 91% facilitating early discharge and treatment planning, and reduced cost of inpatient stay from £2096 in 2006 to £1316 in 2009. Patients treated with optimal surgery followed by radiotherapy with concomitant and adjuvant temozolomide achieved outcomes comparable to those reported in clinical trials: median overall survival 18 months (2-year survival 35%).
Conclusions:
Advancing the management of neuro-oncology patients by moving from an emergency-based system of patient referral and management to a more planned elective outpatient-based pattern of care improves patient experience and has the potential to deliver better outcomes and research opportunities.
doi:10.1038/bjc.2011.153
PMCID: PMC3111193  PMID: 21610702
glioblastoma; management; surgery; radiotherapy; chemotherapy; NICE guidance
13.  Extubation failure in intensive care unit: Predictors and management 
Extubation failure-need for reintubation within 72 h of extubation, is common in intensive care unit (ICU). It can cause increased morbidity, higher costs, higher ICU and hospital length of stay (LOS) and mortality. Patients with advanced age, high severity of illness at ICU admission and extubation, preexisting chronic respiratory and cardiovascular disorders are at increased risk of extubation failure. Unresolved illness, development and progression of organ failure during the time from extubation to reintubation and reintubation itself have been proposed as reasons for increased morbidity and mortality. Parameters used to predict extubation failure can be categorized into parameters assessing respiratory mechanics, airway patency and protection and cardiovascular reserve. Adequate cough strength, minimal secretions and alertness are necessary for successful extubation. Evidence suggests that early institution of non-invasive ventilation and prophylactic administration of methylprednisolone may prevent reintubation in some patients. The intensivist needs to identify patients at high risk of extubation failure and be prepared to reinstitute ventilation early to prevent adverse outcomes.
doi:10.4103/0972-5229.40942
PMCID: PMC2760915  PMID: 19826583
Extubation; failure of; predictors of; reintubation; weaning
14.  Tracheostomy patients on the ward: multiple benefits from a multidisciplinary team? 
Critical Care  2010;14(1):109.
Patients requiring tracheostomies tend to have a longer length of stay due to their underlying disease. After a thorough literature search, Garrubba and colleagues found only three studies assessing the impact of multidisciplinary teams (MDTs) on tracheostomy patients on the ward. One consistent observation was the decreased time to decannulation after institution of MDT care when compared with historical controls. Although a large prospective randomized trial is desirable before MDT is recommended, many institutions may have already formed a team approach to provide coordinated care resulting in improved outcome and length of stay.
doi:10.1186/cc8218
PMCID: PMC2875494  PMID: 20156313
15.  Impact of multidisciplinary team management in head and neck cancer patients 
British Journal of Cancer  2011;104(8):1246-1248.
Background:
We analysed the outcomes of 726 cases of primary head and neck cancer patients managed between 1996 and 2008, including those managed in the multidisciplinary clinic or team setting (MDT) and those managed outside of an MDT by individual disciplines (non-MDT) in the same institution.
Methods:
Data were collected from the Hospital Based Cancer Registry and a database within the Head and Neck Cancer Clinic. Univariable comparisons and multivariable analyses were performed using a logistic regression model. Survival by staging was analysed. Comparisons of management and outcomes were made between MDT and non-MDT patients.
Results:
395 patients (54%) had been managed in the MDT vs 331 patients (46%) non-MDT. MDT patients were more likely to have advanced disease (likelihood ratio χ2=44.7, P<0.001). Stage IV MDT patients had significantly improved 5-year survival compared with non-MDT patients (hazard ratio=0.69, 95% CI=0.51–0.88, P=0.004) and more synchronous chemotherapy and radiotherapy (P=0.004), and the non-MDT group had more radiotherapy as a single modality (P=0.002).
Conclusions:
The improved survival of MDT-managed stage IV patients probably represents both the selection of multimodality treatment and chemotherapeutic advances that these patients received in a multidisciplinary team setting by head and neck cancer specialists as opposed to cancer generalists in a non-MDT setting.
doi:10.1038/bjc.2011.92
PMCID: PMC3078600  PMID: 21448166
multidisciplinary clinic; primary head and neck cancer; survival; cancer management
16.  Measuring the quality of MDT working: an observational approach 
BMC Cancer  2012;12:202.
Background
Cancer multidisciplinary teams (MDTs) are established in many countries but little is known about how well they function. A core activity is regular MDT meetings (MDMs) where treatment recommendations are agreed. A mixed methods descriptive study was conducted to develop and test quality criteria for observational assessment of MDM performance calibrated against consensus from over 2000 MDT members about the “characteristics of an effective MDT”.
Methods
Eighteen of the 86 ‘Characteristics of Effective MDTs’ were considered relevant and feasible to observe. They collated to 15 aspects of MDT working covering four domains: the team (e.g. attendance, chairing, teamworking); infrastructure for meetings (venue, equipment); meeting organisation and logistics; and patient-centred clinical decision-making (patient-centredness, clarity of recommendations). Criteria for rating each characteristic from ‘very poor’ to ‘very good’ were derived from literature review, observing MDMs and expert input. Criteria were applied to 10 bowel cancer MDTs to assess acceptability and measure variation between and within teams. Feasibility and inter-rater reliability was assessed by comparing three observers.
Results
Observational assessment was acceptable to teams and feasible to implement. Total scores from 29 to 50 (out of 58) highlighted wide diversity in quality between teams. Eight teams were rated either ‘very good/good’ or ‘very poor/poor’ for at least three domains demonstrating some internal consistency. ‘Very good’ ratings were most likely for attendance and administrative preparation, and least likely for patient-centredness of decision-making and prioritisation of complex cases. All except two characteristics had intra-class correlations of ≥0.50.
Conclusions
This observational tool (MDT-OARS) may contribute to the assessment of MDT performance. Further testing to confirm validity and reliability is required.
doi:10.1186/1471-2407-12-202
PMCID: PMC3489862  PMID: 22642614
Cancer; Multidisciplinary Communication; Interprofessional relations; Observation; Quality Indicators Health Care; Decision-making; Leadership; Health resources
17.  NICE guidance on the use of carmustine wafers in high grade gliomas: a national study on variation in practice 
British Journal of Neurosurgery  2012;26(3):331-335.
Background. Multidisciplinary team (MDT) working in oncology aims to improve outcomes for patients with cancer. One role is to ensure the implementation of best practice and National Institute for Health and Clinical Excellence (NICE) guidance. In this study, we have assessed the role of MDT in implementing the TA121 appraisal of the use of carmustine wafers in high grade gliomas. Methods. 296 patients with high-grade glioma suitable for maximal resection were recruited from 17 Neurosurgical Centres. The number of patients treated with carmustine wafers and reasons for not using this were recorded. Complications at 48 hours post-operatively and at 6 weeks post-radiotherapy were recorded. Results. 94/296 (32%) of suitable patients received carmustine wafers. In 55% of cases carmustine was not used due to either surgeon preference or a lack of an MDT decision. There was no increased complication rate with carmustine use at either 48 hours post-surgery or at 6 weeks post radiotherapy. Use of carmustine wafers did not decrease access to and use of chemoradiotherapy. Conclusions. One third of patients suitable for carmustine wafers received them. Their use was neither associated with more frequent complications, nor decreased use of chemoradiotherapy. Implementation of NICE TA121 Guidance is extremely variable in different MDTs across the United Kingdom.
doi:10.3109/02688697.2012.673651
PMCID: PMC3432583  PMID: 22482926
Brain neoplasms; implementing NICE guidance; carmustine wafers; improving outcomes guidance
18.  Low preoperative cerebral oxygen saturation is associated with longer time to extubation during fast-track cardiac anaesthesia 
OBJECTIVES
Fast-track cardiac anaesthesia programs aiming at early tracheal extubation have not only been linked to a decrease in intensive care unit and hospital length of stay but also to a decrease in morbidity and mortality as well as a containment of rising medical costs. General recommendations for the inclusion criteria concerning fast-track programs are not available.
METHODS
The present study determined the factors influencing the time to extubation in patients undergoing a newly implemented fast-track protocol. Seventy-nine patients were retrospectively studied. Successful fast track was defined as time to extubation within 75 min after admission to ICU.
RESULTS
Sixty patients fulfilled the successful fast-track criteria with a mean time to extubation of 43.9 min (range 15–75 min). Nineteen patients needed more than 75 min to be weaned from the respirator with a mean time to extubation of 135 min (range 90–320 min). Analysis of pre- and intraoperative factors revealed that these groups differed only with respect to preoperative cerebral oxygen saturation levels: 67.7 ± 5.2 versus 60.8 ± 7.4%.
CONCLUSIONS
Cerebral oxygen saturation assessment prior to cardiac surgery is significantly related to time to extubation and may thus be used to stratify candidates in fast-track programs.
doi:10.1093/icvts/ivs228
PMCID: PMC3422940  PMID: 22691376
Near-infrared spectroscopy; Cerebral oxygen saturation; Cardiac surgery; Fast-track cardiac anaesthesia
19.  Impact of a nurses' protocol-directed weaning procedure on outcomes in patients undergoing mechanical ventilation for longer than 48 hours: a prospective cohort study with a matched historical control group 
Critical Care  2005;9(2):R83-R89.
Introduction
The aim of the study was to determine whether the use of a nurses' protocol-directed weaning procedure, based on the French intensive care society (SRLF) consensus recommendations, was associated with reductions in the duration of mechanical ventilation and intensive care unit (ICU) length of stay in patients requiring more than 48 hours of mechanical ventilation.
Methods
This prospective study was conducted in a university hospital ICU from January 2002 through to February 2003. A total of 104 patients who had been ventilated for more than 48 hours and were weaned from mechanical ventilation using a nurses' protocol-directed procedure (cases) were compared with a 1:1 matched historical control group who underwent conventional physician-directed weaning (between 1999 and 2001). Duration of ventilation and length of ICU stay, rate of unsuccessful extubation and rate of ventilator-associated pneumonia were compared between cases and controls.
Results
The duration of mechanical ventilation (16.6 ± 13 days versus 22.5 ± 21 days; P = 0.02) and ICU length of stay (21.6 ± 14.3 days versus 27.6 ± 21.7 days; P = 0.02) were lower among patients who underwent the nurses' protocol-directed weaning than among control individuals. Ventilator-associated pneumonia, ventilator discontinuation failure rates and ICU mortality were similar between the two groups.
Discussion
Application of the nurses' protocol-directed weaning procedure described here is safe and promotes significant outcome benefits in patients who require more than 48 hours of mechanical ventilation.
doi:10.1186/cc3030
PMCID: PMC1175918  PMID: 15774054
intensive care unit; mechanical ventilation; protocol-directed weaning
20.  Multidisciplinary team approach in breast cancer: a nationwide survey in Korea 
Purpose
This assesses the current workings of multidisciplinary team (MDT) meetings across Korea through surgeons' reports and their current commitments to MDT meetings pertaining to breast cancer, and to determine any perceived areas of potential improvement.
Methods
A questionnaire was sent out to 307 members of The Korean Breast Cancer Society (KBCS) who worked at comprehensive or university medical centers in Korea. The mailing lists of the KBCS members were obtained with the approval of the society. From December 2008 to February 2009, the survey was distributed by surface and electronic mail, with an initial mailing followed by another distribution to non-responders eight weeks later.
Results
Sixty-five individuals (21.2%) returned the completed survey. Of these, 38 responders (62.3%) participated in MDT meetings. Most (97.4%) breast health specialists regarded MDT meetings as an effective method for treatment planning. Most responders (94.7%) reported that the MDT leader was a breast surgeon.
Conclusion
The MDT approach is perceived as an effective method for breast cancer treatment planning and is a feature in most major centers in Korea. Further work is needed to ensure that the MDT approach operates as intended and that all breast cancer patients have access to an MDT.
doi:10.4174/jkss.2012.82.6.340
PMCID: PMC3373983  PMID: 22708095
Neoplasms; Breast; Survey; Multidisciplinary team
21.  A retrospective analysis of determinants of self-extubation in a tertiary care intensive care unit 
Background:
Self-extubation is a common event in intensive care units (ICUs) world-wide. The most common factor attributed in various studies is lack of optimal sedation. However, the factors that lead to this inadequacy of sedation are not analyzed.
Aims:
The present study aimed to evaluate the determinants of factors leading to self-extubation in our ICU. Relation of patient profile, nature of sedation and any diurnal variation in extubation frequency was analyzed
Materials and Methods
Retrospective explorative analysis was carried out for patients admitted to ICU from January 2011 to January 2012. Information from medical records for the above parameters was extracted and descriptive statistics was used for assessing the outcomes.
Results:
In the present study, there was a higher incidence of self-extubation in ventilated ICU patients during the changeover periods of the ICU staff. There was no relation of frequency of self-extubation with the medications used for sedation once the sedation was titrated to a common endpoint. A higher incidence of self-extubation was seen in the surgical and younger age group of patients.
Conclusions:
It is recommended that the duty shift finishing time of ICU staff (medical and paramedical) staff should be staggered and should have minimal overlap to prevent self-extubation. A continuous reassessment of level of sedation of patients independent of the type sedative medication should be carried out.
doi:10.4103/0974-2700.120363
PMCID: PMC3841529  PMID: 24339655
Duty shifts intensive care unit staff; sedation in intensive care unit; self-extubation in intensive care unit
22.  The Endotracheal Tube Air Leak Test Does Not Predict Extubation Outcome in Critically Ill Pediatric Patients 
Objective:
Endotracheal tube air leak pressures (ALT) are used to predict post-extubation upper airway compromise such as stridor, upper airway obstruction, or risk of reintubation. To determine if the absence of an endotracheal tube air leak (ALT ≥ 30 cm H2O) measured during the course of mechanical ventilation predicts extubation failure in infants and children.
Design:
Prospective, blinded cohort.
Setting:
Multidisciplinary pediatric intensive care unit of a university hospital.
Patients:
Patients age ≤ 18 years and intubated ≥ 24 hours
Interventions
The pressure required to produce an audible endotracheal tube air leak was measured within 12 hours of intubation and extubation. Unless prescribed by the medical care team, patients did not receive neuromuscular blocking agents during ALT measurements.
Measurements and Main Results:
The need for reintubation (i.e., extubation failure) was recorded during the 24 hour post-extubation period. Seventy-four patients were enrolled resulting in 59 observed extubation trials. The extubation failure rate was 15.3% (9/59). Seven patients were treated for post-extubation stridor. Extubation failure was associated with a longer median length of ventilation, 177 vs. 78 hours, p=0.03. Extubation success was associated with the use of post-extubation non-invasive ventilation (p = 0.04).
The air leak was absent for the duration of mechanical ventilation (i.e., ≥ 30 cm H2O at intubation and extubation) in ten patients. Absence of the air leak did not predict extubation failure (negative predictive value, NPV 27%, 95% CI 6% to 60%). The ALT was ≥ 30 cm H2O prior to extubation in 47% (28/59) of patients yet 23 patients extubated successfully (NPV 18%).
Conclusions:
An endotracheal tube air leak pressure ≥ 30 cm H2O measured in the non-paralyzed patient prior to extubation or for the duration of mechanical ventilation was common and did not predict an increased risk for extubation failure. Pediatric patients who are clinically identified as candidates for an extubation trial but do not have an endotracheal tube air leak may successfully tolerate removal of the endotracheal tube.
doi:10.1097/PCC.0b013e3181849901
PMCID: PMC2782931  PMID: 18679147
air leak test; cuff leak test; predictor variables; extubation; mechanical ventilation; endotracheal tube leak; respiratory failure; pediatric; neonate; stridor; non-invasive ventilation
23.  Effects of mechanical insufflation-exsufflation in preventing respiratory failure after extubation: a randomized controlled trial 
Critical Care  2012;16(2):R48.
Introduction
Weaning protocols that include noninvasive ventilation (NIV) decrease re-intubation rates and ICU length of stay. However, impaired airway clearance is associated with NIV failure. Mechanical insufflation-exsufflation (MI-E) has been proven to be very effective in patients receiving NIV. We aimed to assess the efficacy of MI-E as part of an extubation protocol.
Method
Patients with mechanical ventilation (MV) for more than 48 hours with specific inclusion criteria, who successfully tolerated a spontaneous breathing trial (SBT), were randomly allocated before extubation, either for (A) a conventional extubation protocol (control group), or (B) the MI-E extubation protocol (study group). During the postextubation period (48 hours), group A patients received standard medical treatment (SMT), including NIV in case of specific indications, whereas group B received the same postextubation approach plus three daily sessions of mechanical in-exsufflation (MI-E). Reintubation rates, ICU length of stay, and NIV failure rates were analyzed.
Results
Seventy-five patients (26 women) with a mean age of 61.8 ± 17.3 years were randomized to a control group (n = 40; mean SAPS II, 47.8 ± 17.7) and to a study group (n = 35; mean SAPS II, 45.0 ± 15.0). MV time before enrollment was 9.4 ± 4.8 and 10.5 ± 4.1 days for the control and the study group, respectively. In the 48 hours after extubation, 20 control patients (50%) and 14 study patients (40%) used NIV. Study group patients had a significant lower reintubation rate than did controls; six patients (17%) versus 19 patients (48%), P < 0.05; respectively, and a significantly lower time under MV; 17.8 ± 6.4 versus 11.7 ± 3.5 days; P < 0.05; respectively. Considering only the subgroup of patients that used NIV, the reintubation rates related to NIV failure were significantly lower in the study group when compared with controls; two patients (6%) versus 13 (33%); P < 0.05, respectively. Mean ICU length of stay after extubation was significantly lower in the study group when compared with controls (3.1 ± 2.5 versus 9.8 ± 6.7 days; P < 0.05). No differences were found in the total ICU length of stay.
Conclusion
Inclusion of MI-E may reduce reintubation rates with consequent reduction in postextubation ICU length of stay. This technique seems to be efficient in improving the efficacy of NIV in this patient population.
doi:10.1186/cc11249
PMCID: PMC3681374  PMID: 22420538
24.  Holistic management of DSD 
Disorder of sex development (DSD) presents a unique challenge, both diagnostically and in terms of acute and longer-term management. These are relatively rare conditions usually requiring a multidisciplinary approach from the outset and the involvement of a tertiary centre for assessment and management recommendations. This article describes the structure of the multidisciplinary team (MDT) at our centre, with contributions from key members of the team regarding their individual roles. The focus is on the newborn referred for assessment of ambiguous genitalia, rather than on individuals who present in the adolescent period or at other times, although the same MDT involvement is likely to be required. The approach to the initial assessment and management is discussed and the subsequent diagnosis and follow-up presented, with emphasis on the importance of careful transition and long-term support.
doi:10.1016/j.beem.2010.01.006
PMCID: PMC2892742  PMID: 20541156
disorder of sex development (DSD); intersex; multidisciplinary team; congenital adrenal hyperplasia; gonadal dysgenesis; ambiguous genitalia
25.  The Preoperative Assessment of Hepatic Tumours: Evaluation of UK Regional Multidisciplinary Team Performance 
HPB Surgery  2013;2013:861681.
Introduction. In the UK, patients where liver resection is contemplated are discussed at hepatobiliary multidisciplinary team (MDT) meetings. The aim was to assess MDT performance by identification of patients where radiological and pathological diagnoses differed. Materials and Methods. A retrospective review of a prospectively maintained database of all cases undergoing liver resection from March 2006 to January 2012 was performed. The presumed diagnosis as a result of radiological investigation and MDT discussion is recorded at the time of surgery. Imaging was reviewed by specialist gastrointestinal radiologists, and resultswereagreedonby consensus. Results. Four hundred and thirty-eight patients were studied. There was a significant increase in the use of preoperative imaging modalities (P ≤ 0.01) but no change in the rate of discrepant diagnosis over time. Forty-two individuals were identified whose final histological diagnosis was different to that following MDT discussion (9.6%). These included 30% of patients diagnosed preoperatively with hepatocellular carcinoma and 25% with cholangiocarcinoma of a major duct. Discussion. MDT assessment of patients preoperatively is accurate in terms of diagnosis. The highest rate of discrepancies occurred in patients with focal lesions without chronic liver disease or primary cancer, where hepatocellular carcinoma was overdiagnosed and peripheral cholangiocarcinoma underdiagnosed, where particular care should be taken. Additional care should be taken in these groups and preoperative multimodality imaging considered.
doi:10.1155/2013/861681
PMCID: PMC3766576  PMID: 24062601

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