Formal responsibility and task execution: the importance of modelling task delegation in FRAM to optimise the identification of potential improvement strategies.

Performance of large language models and clinical decision support in perioperative management of oral anticoagulants.

Perioperative management of antithrombotic therapy in patients with thrombotic antiphospholipid syndrome.

Perioperative Management of Oral Anticoagulation

Patients with mechanical heart valve replacement require lifelong anticoagulation therapy, and additional surgeries can pose a risk of bleeding and thromboembolic events due to the need for perioperative anticoagulation management. Here, we present a case report of a patient who underwent laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP) after mechanical heart valve replacement and experienced postoperative cerebral embolism. The management of perioperative anticoagulation in these patients is discussed, including strategies for minimizing the risks of bleeding and thromboembolic events during and after surgery.

Hospital is the medical institution where sick or injured people are given medical or surgical care irrespective of their socio-economic status. Health care givers and administrators are considered as health care professionals. The form of hospital services, their organization, development, operation and administration have undergone significant differentiations during the last 20 years. Public dissatisfaction with the traditional role of hospitals has grown vastly which may be attributed to the implementation of issues such as changed quality of life and cost-effectiveness, wide media coverage of system inadequacies, increased demands and awareness of patient’s rights, limited resources in the era of expensive hi-tech medical support systems and traditional approaches of regulatory bodies. Hospitals across the country are searching for effective quality improvement strategies. Implementation of care pathways in the hospital management will improve the quality of care, standardization of care processes, bring into limelight the existing flaws, suggest ways for future improvements, help to utilize resources in a cost effective manner which is essential both in developed as well as developing countries. In this review attempts have been made to highlight on the strategic points like the implementations and utilities of clinical care pathways and its role in the control of emergency medical cases like strokes, importance of timelines and key performance indicators of health administrators, effectiveness of clinical decision making of medical professionals and their overall contribution in the quality improvement of health care and thus hospital management. © 2011 IGJPS. All rights reserved

O presente estudo busca refletir e discutir sobre qual a percepção que professores e professoras têm acerca do conceito de saúde mental e sua própria condição de saúde mental. Trata-se de um estudo descritivo exploratório desenvolvido em uma escola estadual de ensino médio, em um município da fronteira oeste do Estado do Rio Grande do Sul. Foi aplicado um questionário contendo questões abertas e fechadas, com questões norteadoras. A análise dos dados foi fundamentada na análise de conteúdo, com desmembramento das respostas em categorias. Participaram do estudo 33 professoras e 7 professores, totalizando 40 indivíduos. Através da análise dos dados foi possível perceber que os professores e professoras da escola apresentam um entendimento superficial sobre o conceito saúde mental, relacionando a ações comportamentais e atitudinais. Visualizam o seu estado de saúde mental como prejudicado, trazendo o estresse e esgotamento como os principais motivos para tal situação, além de visualizarem influências da rotina e ambiente de trabalho, como a desvalorização profissional e relação interpessoal como fatores de influência em seu estado de saúde mental. Tais resultados auxiliam a uma melhor compreensão da temática entre a população abordada, contribuindo para o desenvolvimento de estratégias mais eficazes de melhoria e de promoção a saúde mental.

BackgroundTranslating scientific evidence into daily practice is complex. Clinical guidelines can improve health care delivery, but there are a number of challenges in guideline adoption and implementation. Factors influencing the effective implementation of guidelines remain poorly understood. Understanding of barriers and facilitators is important for development of effective implementation strategies. The aim of this study was to determine perceived facilitators and barriers to guideline implementation and clinical compliance to guidelines for depression in psychiatric care.MethodsThis qualitative study was conducted at two psychiatric clinics in Stockholm, Sweden. The implementation activities at one of the clinics included local implementation teams, seminars, regular feedback and academic detailing. The other clinic served as a control and only received guidelines by post. Data were collected from three focus groups and 28 individual, semi-structured interviews. Content analysis was used to identify themes emerging from the interview data.ResultsThe identified barriers to, and facilitators of, the implementation of guidelines could be classified into three major categories: (1) organizational resources, (2) health care professionals' individual characteristics and (3) perception of guidelines and implementation strategies. The practitioners in the implementation team and at control clinics differed in three main areas: (1) concerns about control over professional practice, (2) beliefs about evidence-based practice and (3) suspicions about financial motives for guideline introduction.ConclusionsIdentifying the barriers to, and facilitators of, the adoption of recommendations is an important way of achieving efficient implementation strategies. The findings of this study suggest that the adoption of guidelines may be improved if local health professionals actively participate in an ongoing implementation process and identify efficient strategies to overcome barriers on an organizational and individual level. Getting evidence into practice and implementing clinical guidelines are dependent upon more than practitioners' motivation. There are factors in the local context, e.g. culture and leadership, evaluation, feedback on performance and facilitation, -that are likely to be equally influential.

Deciphering the genetics of quantitative traits of economic importance provides valuable guidance to plant breeders in choosing appropriate breeding strategies for yield improvement. The objective of this study was to assess the nature and magnitude of gene effects controlling quantitative traits in bread wheat through generation mean analysis to formulate effective breeding strategies for yield improvement. Six generations, P 1 , P 2 , F 1 , F 2 , B 1 , and B 2 , derived from six crosses (HPW 155 × ONS 27, HPW 349 × HSB 6, HPW 368 × ONS 29, HPW 368 × ONS 27, PBW 343 × ONS 29, and HS 562 × ONS 29) were evaluated in a compact family block design during the rabi season of 2018–19. Results demonstrated that the six‐parameter model provided the best‐fit for explaining the inheritance of grain yield, indicating that, alongside additive and dominance effects, epistatic effects (additive × additive, additive × dominance, and dominance × dominance) play a critical role in governing this trait. Significant and positive epistasis, coupled with the predominance of duplicate epistasis, was observed for grain yield per plant in the crosses HPW 155 × ONS 27, HPW 368 × ONS 29, HPW 349 × HSB 6, HPW 368 × ONS 27, and HS 562 × ONS 29. These findings suggest that biparental mating and recurrent selection, with delayed selection in later segregating generations, are the most effective strategies for yield improvement.

Background: The governmental Caring Neighborhoods initiative in Flanders (Belgium) is a driver for the exploration of collaboration between informal actors (citizens, families, neighbors, informal caregivers, ...) and professional actors (healthcare, social care, housing, culture, ...). Several neighborhoods advance a digital neighbourhood platform as a means of communication, participation, and matchmaking between people who want and offer neighborly support. Healthcare and social professionals often meet people who could use neighborly support. In this project, we explore the potential to integrate digital neighbourhood platforms in daily practices together with these professionals. Target group: Healthcare and social professionals. Involved and engaged stakeholders: Citizens, families, neighbors, informal caregivers, housing, culture, ... Intervention: The researchers become active partners in the development of five caring neighborhoods, co-creating and evaluating the potential of the platforms through the participation in project meetings, work groups, partner meetings, workshops, steering committees, ... Content analysis is performed to distinguish themes and patterns in the data, answering the realist evaluation question: what works for who, in which circumstances? Results: The potential of the digital neighbourhood platforms depends on the functionality of the platform, the fit with the neighbourhood needs and context, the pre-existing collaborative dynamics in the neighbourhood, and the willingness and capability of professionals to integrate the platform into daily practices. Platforms have different goals (e.g. sharing economy vs. social community) and functions (e.g. neighborly support matchmaking and/or communication). Platforms have a limited potential for vulnerable citizens, groups and neighborhoods. 'Offline' community organizing, both informally and professionally, remains important in any case, but especially for the most vulnerable. Several caring neighbourhood projects are experimenting with hybrid combinations of 'online' and 'offline' community organizing and neighborly help, but both knowledge and skills as well as collaborative processes have to be further developed to better address the individual and community needs and for professionals to integrate the platforms in daily practices. Lessons for international audience: - The potential and limitations of digital neighbourhood platforms are tied to the needs and contexts of different neighborhoods, and to the pre-existing informal and professional networks and their ongoing collaborative dynamic. - A co-creative, participative research methodology helps to shed light on the intricate differences between different neighborhoods, caring neighbourhood projects, and their respective dynamics. Next steps: The lessons learned are translated into accessible information and services for local governments, healthcare and social care. Future research should further look into the potential of digital neighbourhood platforms in the context of caring neighborhoods from the citizen perspective.

12012 Background: Geriatric assessment (GA) is recommended in various guidelines for older adults with cancer, but is not widely used in daily practice. This study aims to identify multi-level barriers and facilitators of GA implementation in daily oncology practice, based on a theoretical implementation framework. Methods: We conducted 20 semi-structured interviews with healthcare providers and managers in 14 hospitals treating older adults with cancer in Japan. The Consolidated Framework for Implementation Research (CFIR) was used to guide the collection and analysis of interview data using a deductive approach. CFIR consists of 5 major domains (I. intervention characteristics, II. outer setting, inner setting,. individual characteristics, and V. process), including 39 constructs. Differences in the constructs influencing GA implementation between hospitals where GA is routinely performed (high implementation, HI) and hospitals where GA is not performed or performed only in clinical trials (low implementation, LI) were explored. Results: Among constructs identified as barriers or facilitators of GA implementation, 15 multi-level constructs greatly differed between 5HI and 5LI, including 4 constructs from intervention characteristics, 6 from inner setting, 1 from individual characteristics, and 4 from process. In HI, GA was self-administered (I. adaptability), or administered on a mobile app with interpretation (I. design quality and packaging). In HI, healthcare providers strongly perceived the need to change the practice for older adults (III. tension for change), and recognized GA as fitting in with existing workflow as part of their jobs (III. compatibility). In LI, they did not realize the need to change practice, and rejected GA as an extra burden on their heavy workload. In HI, the usefulness of GA was widely recognized by healthcare providers (IV. knowledge and beliefs about the intervention), GA was given high priority (III. relative priority), had strong support from hospital directors and nursing chiefs (V. leadership engagement), and multiple stakeholders were successfully engaged, such as healthcare providers, especially nurses (V. key stakeholders), directors and nursing chiefs (V. opinion leaders), and those who dedicated themselves to implementing GA (champions). Conclusions: This is the first study to reveal the multi-level barriers and facilitators of GA implementation in daily oncology practice. The findings highlight the need to focus not only on individual or intervention characteristics, but also on the inner setting and the process of implementing GA. Our findings suggest future strategies, such as devising the administration of GA using technology, conducting local needs assessment and consensus discussions about the usefulness and priority of GA, and engaging multiple stakeholders.

An increasing number of patients are receiving long‑term oral anticoagulant therapy and the availability of new oral anticoagulants (OACs), which are easier to use than warfarin, will further expand the population of anticoagulated patients. As a consequence, an increasing number of patients will need perioperative anticoagulant management because of elective or nonelective surgery or procedures. The perioperative management of such patients is pertinent to a broad spectrum of physicians, including anesthesiologists, internists, and surgeons. The objectives of this review are to provide a clinically‑focused background on the pharmacology of warfarin and the new OACs and to suggest perioperative anticoagulant management strategies. This review will focus on the perioperative management of warfarin and new OACs who require urgent or emergent surgery or who require rapid anticoagulant reversal because of ongoing bleeding or high bleeding risk.

The latest updates to the NCCN Guidelines for perioperative management of anticoagulation and antithrombotic therapies reflect significant changes in the use of bridging anticoagulation. For patients with low- to intermediate-risk atrial fibrillation, the standard of care has shifted toward reduced reliance on bridging anticoagulation. The rationale for this shift is based on the BRIDGE trial, which revealed a 3-fold greater risk of major bleeding without significant reduction in thrombotic outcomes in patients receiving bridging therapy. In patients with mechanical heart valves, findings from the PERIOP2 study led to similar conclusions. Both of these studies have contributed to a paradigm shift in perioperative anticoagulation management, pivoting toward personalized therapy based on patient-specific bleeding and thrombotic risks. For emergent or elective surgeries, the NCCN Guidelines provide a framework for more individualized decision-making, emphasizing the need for ongoing cooperation among physicians, surgeons, and patients.

The decision to stop or continue anticoagulants or antiplatelet therapy for oculoplastic procedures has long been a complicated and serious discussion for surgeons and their patients. Although other specialties have developed evidenced-based algorithms to guide their decision-making our subspecialty remains driven largely by anecdotal information. This article aims to get closer to an evidenced-based approach to perioperative anticoagulant and antiplatelet management. Over the last few years, new antiplatelet and anticoagulant therapies are on the market with different characteristics in terms of half-life and mechanism of action. It is imperative the contemporary surgeon be well versed in these new medications. Also, new studies have emerged from the vascular literature with specific evidenced-based recommendations for heart and stroke patients. These guidelines need to be weighed with a patient's cardiologist or neurologist. The article will review the old and new anticoagulant and antiplatelet therapies as well as the recent literature for stroke and cardiac patients to guide the oculoplastic surgeon in this nuanced decision. It will also discuss current practice patterns in light of these new therapies and medical guidelines.

Comparative Analysis of Perioperative Anticoagulation Management Guidelines across U.S. Institutions

Hospital quality improvement initiatives that focus on the patient experience are increasingly gaining attention. One of the known improvement methodologies is patient journey mapping. Central to this methodology is the mapping process, resulting in a patient journey map: a visual presentation of the complete route a patient follows during all stages of a care trajectory and the patients emotional experience during this journey: the patient journey map. Currently, there is no standard approach on how to perform the steps in the mapping process and evidence is lacking on the most effective and efficient way. As a result, the adoption of the methodology by healthcare professionals is hindered, more time than necessary is spent on the mapping and a lot of significant variation exists in the quality of the resulting patient journey maps. The Lean methodology has a proven track of record to optimize and standardize processes. Hence, by performing a Lean analysis onto the patient journey mapping process, opportunities to optimize and standardize the process may be identified. This study aimed to assess the value of Lean methodology to optimize patient journey mapping in a hospital setting. Observations and interviews were performed to identify the process for patient journey mapping in a Dutch academic hospital. Lean was used to visualize the process and identify inefficiencies. An expert panel reviewed the improvement suggestions. We conclude that Lean can provide value for aligning different views on the process, for structuring the process steps and phases and for identifying optimization actions in the mapping process.