Resource stratified versus sub-optimal care: multi-disciplinary care settings as the arbiter.

This study aimed to explore the experiences of migrant people living with HIV (MLWH) enrolled in a Montreal-based multidisciplinary HIV care clinic with rapid antiretroviral treatment (ART) initiation and cost-covered ART. Between February 2020 and March 2022, 32 interviews were conducted with 16 MLWH at three time-points (16 after 1 week of ART initiation, 8 after 24 weeks, 8 after 48 weeks). Interviews were analyzed via the Framework Method. Thirty categories were identified, capturing experiences across the HIV care cascade. At diagnosis, most MLWH described “initially experiencing distress”. At linkage, almost all MLWH discussed “navigating the health system with difficulty”. At treatment initiation, almost all MLWH expressed “being satisfied with treatment”, particularly due to a lack of side effects. Regarding care retention, all MLWH noted “facing psychosocial or health-related challenges beyond HIV”. Regarding ART adherence, most MLWH expressed “being satisfied with treatment” with emphasis on their taking control of HIV. At viral suppression, MLWH mentioned “finding more peace of mind since becoming undetectable”. Regarding their perceived health-related quality of life, most MLWH indicated “being helped by a supportive social network”. Efficient, humanizing, and holistic approaches to care in a multidisciplinary setting, coupled with rapid and free ART initiation, seemed to help alleviate patients’ concerns, address their bio-psycho-social challenges, encourage their initial and sustained engagement with HIV care and treatment, and ultimately contribute to positive experiences.

The kidney failure risk equation (KFRE) can be used to predict progression to end-stage kidney disease in a clinical setting. Evaluate implementation of a formalized risk-based approach in nephrologists' outpatient clinics and multidisciplinary chronic kidney disease (CKD) clinics to determine candidacy for multidisciplinary care, and the impact of CKD care selection on clinical outcomes. Population-based descriptive cohort study. Alberta Kidney Care South. Adults attending or considered for a multidisciplinary CKD clinic between April 1, 2017, and March 31, 2019. Exposure-The course of CKD care assigned by the nephrologist: management at multidisciplinary CKD clinic; management by a nephrologist or primary care physician. Primary Outcome-CKD progression, defined as commencement of kidney replacement therapy (KRT). Secondary Outcomes-Death, emergency department visits, and hospitalizations. We linked operational data from the clinics (available until March 31, 2019) with administrative health and laboratory data (available until March 31, 2020). Comparisons among patient groups, courses of care, and clinical settings with negative binomial regression count models and calculated unadjusted and fully adjusted incidence rate ratios. For the all-cause death outcome, we used Cox survival models to calculate unadjusted and fully adjusted hazard ratios. Of the 1748 patients for whom a KFRE was completed, 1347 (77%) remained in or were admitted to a multidisciplinary CKD clinic, 310 (18%) were managed by a nephrologist only, and 91 (5%) were referred back for management by their primary care physician. There was a much higher kidney failure risk among patients who remained at or were admitted to a multidisciplinary CKD clinic (median 2-year risk of 34.7% compared with 3.6% and 0.8% who remained with a nephrologist or primary care physician, respectively). None of the people managed by their primary care physician alone commenced KRT, while only 2 (0.6%) managed by a nephrologist without multidisciplinary CKD care commenced KRT. The rates of emergency department visits, hospitalizations, and death were lower in those assigned to management outside the multidisciplinary CKD clinics when compared with those managed in the multidisciplinary care setting. The follow-up period may not have been long enough to determine outcomes, and potentially limited generalizability given variability of care in multidisciplinary clinics. Our findings indicate that a portion of patients can be directed to less resource-intensive care without a higher risk of adverse events. Not applicable.

Routine outcome monitoring of common mental health disorders (CMHDs), using patient reported outcome measures (PROMs), has been promoted across primary care, psychological therapy and multidisciplinary mental health care settings, but is likely to be costly, given the high prevalence of CMHDs. There has been no systematic review of the use of PROMs in routine outcome monitoring of CMHDs across these three settings. To assess the effects of routine measurement and feedback of the results of PROMs during the management of CMHDs in 1) improving the outcome of CMHDs; and 2) in changing the management of CMHDs. We searched the Cochrane Depression Anxiety and Neurosis group specialised controlled trials register (CCDANCTR-Studies and CCDANCTR-References), the Oxford University PROMS Bibliography (2002-5), Ovid PsycINFO, Web of Science, The Cochrane Library, and International trial registries, initially to 30 May 2014, and updated to 18 May 2015. We selected cluster and individually randomised controlled trials (RCTs) including participants with CMHDs aged 18 years and over, in which the results of PROMs were fed back to treating clinicians, or both clinicians and patients. We excluded RCTs in child and adolescent treatment settings, and those in which more than 10% of participants had diagnoses of eating disorders, psychoses, substance use disorders, learning disorders or dementia. At least two authors independently identified eligible trials, assessed trial quality, and extracted data. We conducted meta-analysis across studies, pooling outcome measures which were sufficiently similar to each other to justify pooling. We included 17 studies involving 8787 participants: nine in multidisciplinary mental health care, six in psychological therapy settings, and two in primary care. Pooling of outcome data to provide a summary estimate of effect across studies was possible only for those studies using the compound Outcome Questionnaire (OQ-45) or Outcome Rating System (ORS) PROMs, which were all conducted in multidisciplinary mental health care or psychological therapy settings, because both primary care studies identified used single symptom outcome measures, which were not directly comparable to the OQ-45 or ORS.Meta-analysis of 12 studies including 3696 participants using these PROMs found no evidence of a difference in outcome in terms of symptoms, between feedback and no-feedback groups (standardised mean difference (SMD) -0.07, 95% confidence interval (CI) -0.16 to 0.01; P value = 0.10). The evidence for this comparison was graded as low quality however, as all included studies were considered at high risk of bias, in most cases due to inadequate blinding of assessors and significant attrition at follow-up.Quality of life was reported in only two studies, social functioning in one, and costs in none. Information on adverse events (thoughts of self-harm or suicide) was collected in one study, but differences between arms were not reported.It was not possible to pool data on changes in drug treatment or referrals as only two studies reported these. Meta-analysis of seven studies including 2608 participants found no evidence of a difference in management of CMHDs between feedback and no-feedback groups, in terms of the number of treatment sessions received (mean difference (MD) -0.02 sessions, 95% CI -0.42 to 0.39; P value = 0.93). However, the evidence for this comparison was also graded as low quality. We found insufficient evidence to support the use of routine outcome monitoring using PROMs in the treatment of CMHDs, in terms of improving patient outcomes or in improving management. The findings are subject to considerable uncertainty however, due to the high risk of bias in the large majority of trials meeting the inclusion criteria, which means further research is very likely to have an important impact on the estimate of effect and is likely to change the estimate. More research of better quality is therefore required, particularly in primary care where most CMHDs are treated.Future research should address issues of blinding of assessors and attrition, and measure a range of relevant symptom outcomes, as well as possible harmful effects of monitoring, health-related quality of life, social functioning, and costs. Studies should include people treated with drugs as well as psychological therapies, and should follow them up for longer than six months.

ABSTRACTBackgroundThere is limited real‐world evidence on predictive factors for good outcomes in patients with chronic neuropathic pain (NP) treated in multidisciplinary tertiary care centres. This study aimed to identify subgroups of NP patients with similar pain trajectories and evaluate associated factors.MethodsWe analysed data from 912 patients with chronic NP (age: 53.6 ± 13.3 years; 51.5% female) enrolled in the Quebec Pain Registry, all of whom reported a baseline pain intensity of ≥ 4/10. Patients completed standardised questionnaires prior to treatment initiation, as well as at 6 and 12 months. Pain trajectories were identified using group‐based trajectory modelling (GBTM), with multiple imputation performed to address missing data. The results were confirmed using group‐mixture modelling on the non‐imputed dataset and using GBTM in the subgroup of patients with complete data.ResultsA three‐class trajectory model best fitted the data for both pain intensity and interference. Only 23.1% of patients showed a clear improvement in pain intensity, while 23.5% showed improvement in pain interference. Key predictors of pain intensity improvement included lower baseline pain intensity and interference. Improvement in pain interference was associated with lower baseline interference and depression scores, as well as shorter pain duration. Notably, receiving a strong opioid significantly increased the risk (RR = 1.45 [1.17; 1.78]) of belonging to the persisting severe pain trajectory.ConclusionsA minority of chronic NP patients demonstrated significant improvement with multidisciplinary treatment. These findings highlight the limitations of current management strategies and emphasise the need for novel therapeutic approaches to address the burden of chronic NP effectively.SignificanceThis study highlights the value of trajectory analysis in identifying subgroups of patients with chronic neuropathic pain (NP) who exhibit different patterns of treatment response. Only a minority of patients—approximately 23% for both pain intensity and pain interference—demonstrated meaningful improvement. Lower baseline pain intensity and interference emerged as key predictors of better outcomes, while strong opioid use was associated with persistent severe pain. These findings underscore the importance of trajectory‐based approaches for understanding the course of NP and for guiding more personalised and effective management in multidisciplinary care settings.

As members of a research team conducting a large national study to examine the clinical leadership development needs among nurses and midwives in Ireland (Fealy et al. 2009), we were struck by two facts that seemed to us to have rather profound implications for both research conduct and clinical practice. The first concerned the range and quality of the body of literature on the topic of leadership. The second, derived from our research data, was the great difficulty that nurses and midwives seem to experience in clearly articulating their discipline-specific or differentiated contribution to care in the multidisciplinary context. On the range and quality of literature on the topic of leadership, we arrived at several conclusions, some of which are alarming. The topic of leadership has given rise to a bewildering array of books, articles, commentary pieces and websites on leadership theory and on the various ways that leadership finds practical expression in organisational contexts and within social practices. However, despite the myriad literature on the subject, much that is written is often dense and opaque, contradictory and inconclusive and much of the material draws on other published writings that seem to have no obvious empirical foundations. We characterised the body of literature on leadership according to the relative emphasis placed on the leader type, leadership behaviours or the context in which leadership takes place but, otherwise, concluded that despite all that is written on the subject, little is derived from research evidence (Fealy et al. 2009). Moreover, the means and the ends of writing on the subject seem confused, whereby the process of writing about leadership seems to have become an end in itself. Rather than offering a clear understanding of a complex human and social phenomenon, all that the literature has achieved is to obfuscate and to grow careers for those in a growth ‘industry’ of leadership books, websites and courses. Jackson and Watson (2009) have also raised some similar concerns regarding leadership, including a concern about the quality of published scholarship in the field. They write that leadership, as a concept, is rarely critiqued, that there is a paucity of published empirical research on clinical leadership development in nursing, and they express concern that there is a tendency to represent leadership as a generic concept, thereby failing to recognise its context specificity. They also draw attention to the fact that an industry of leadership courses has grown across a range of disciplines to satisfy the perceived need for leadership knowledge and skills on the part of employers and employees alike, but given the context specificity of leadership, they pose the fundamental question: ‘can effective leadership be taught’ (Jackson & Watson 2009: 1962). Our particular critique applies to the general body of literature on leadership theory emanating from a range of academic and practise disciplines and to the expanding body of literature on leadership in nursing and midwifery, most of which seems content to ape the trend of mass production and obfuscation that we observed in the wider academic press on the topic. This rather stark conclusion is not to cast aside all that is written on the subject but rather to make a plea to those writing about and researching the subject in our particular disciplines to assume a truly critical stance. As a concept, leadership should be reexamined with reference to its essential attributes and, in so far as leadership really does exist, evidence for its particular and unique expressions in our disciplines should be sought through research. In this same connection, we support Jackson and Watson’s (2009: 1962) call for scholarly papers and research reports that critically examine leadership issues in nursing and ‘scrutinise those leadership interventions and strategies that are successful and effective, as well as those that are unsuccessful and ineffective.’ Journal editors have a clear responsibility in this regard and need to be more discerning in the sort of manuscripts that they accept on the subject. What is needed is a renaissance in the scholarship on leadership. When conducting the national clinical leadership needs analysis study, we concluded from our review of literature that clinical leadership was not the preserve of a few senior clinicians but concerned all clinicians and an essential attribute of clinical leadership is the ability to articulate the discipline-specific contribution to care (Fealy et al. 2009). That is, clinical leaders must be able to articulate the distinct nursing or midwifery contribution within multidisciplinary care settings and advance their particular disciplinary perspectives in the practicum and in wider multidisciplinary contexts, including policy fora. Articulating the distinct contribution in the practicum involves both words and actions. Clinical leaders’ particular clinical expertise delimits their scope of clinical practice but also confers on them their disciplinary identity in the multidisciplinary context. When warranted in the care planning and evaluation processes, clinical leaders are able to clearly, credibly and convincingly represent their specialised and differentiated expert contribution. In our research, we sought evidence of this particular attribute of clinical leadership, through a needs analysis questionnaire and through focus group discussions among nurses and midwives across all grades. Evidence from both data sources suggests that nurses’ and midwives’ clinical leadership development needs were greatest at the multidisciplinary team, interdepartmental and organisational interfaces. While their clinical work involves direct care activities, much of their work is concerned with coordinating and orchestrating care and other administrative functions of the multidisciplinary team and in this work they are constantly acting to compensate for deficiencies and gaps in service and care provision. This ‘compensatory mode’ results in the systematic effacement of nurses’ and midwives’ particular contributions to patient care as they are distracted from their therapeutic practice by an organisational imperative to metaphorically ‘push’ and ‘pull’ patients through beds to achieve the goals of clinical medicine and healthcare management, a phenomenon also observed by Latimer (2000) in the English context. These compensatory activities determine the scope and content of the care that nurses and midwives can provide, and constrain and dissipate their ability to demonstrate and articulate their unique contribution to patient outcomes; this ultimately has an impact on their ability to develop as clinical leaders for their professions. Without the capacity, adequately, to represent their professional disciplinary contributions at the team, unit, organisational and wider heath system levels, nurses and midwives are denied a powerful source of authority, credibility, legitimacy and status with which to negotiate their own identities and interdisciplinary relationships (Chouliaraki & Fairclough 1999). Instead, power remains concentrated elsewhere, embedded in other disciplines, whose discourses nurses and midwives often expropriate in an attempt to render themselves and their work visible and audible (Latimer 2000). This may, to some extent, explain the colonisation of much of nursing and midwifery discourse, not only by biomedical discourse but also by the managerialist and leadership discourses discussed previously. Based on the findings of her own and others’ empirical work, further support for which is provided by our own study, Allen (2004) urges an explicit recognition and acceptance that the nurse’s role is precisely that of a healthcare mediator; the nurse is the ultimate flexible worker, juggling competing priorities, channelling information and, crucially, blurring her/his professional and disciplinary boundaries to create order and facilitate patients’ passage through the healthcare system while ensuring continuity of care. Nursing becomes the connective tissue filling the interstices and binding together all the other healthcare cells, with their distinctive functions and related structures, within the health system organ. While this function may be a necessary aspect of the nurse’s and midwife’s role, particularly within health systems as currently configured, we want to argue that it should not exhaust the totality of the nursing or midwifery contribution to care, and is, to a large extent, a by-product of a dysfunctional healthcare system and of nurses’ and midwives’ inability to resist more powerful discourses. In isolation, the essentially technical and administrative role of healthcare mediator offers a rather impoverished and eviscerated construction of nursing and erases the notion of any distinctive professional clinical and therapeutic contribution to care. Clinical leaders of nursing and midwifery need to resist any such restricted version of their disciplines and to do this will need to articulate a discourse that outlines the scope, content and future of nursing and midwifery as professional clinical disciplines. Acquiring this discourse and articulating it in clinical and policy arenas are essential attributes of the clinical leader. Academics have a critical role in enabling nurses and midwives to acquire this discourse, to demonstrate in words and actions the legitimacy of their distinct clinical work, including work associated with bodily care, and to render it visible in a range of multidisciplinary contexts, including clinical care and healthcare planning. However, in this connection, a major challenge is the fact that many academics do not themselves possess the sort of specialised and coherent discourse or the requisite nursing and academic capital, being ‘insulated and removed from the realities of clinical practice’ (McNamara 2009: 1577). Indeed, many academics seem content to profess anything but nursing (Thompson & Watson 2006), including leadership and management. Those academics who seem content to add yet more ‘theory’ to the already innumerable theories on leadership development might better serve their discipline by assisting clinicians to acquire a discourse that will enable them to articulate coherently their differentiated clinical contribution to care, and thereby enable them to become clinical leaders. The national clinical leadership study referred to in this Editorial was commissioned by the (Irish) Health Service Executive and the National Council for the Professional Development of Nursing & Midwifery. We acknowledge their contribution and that of the other members of the research team, whose names appear in the reference list.

Fired Up, Ready to Go-- Pediatric and Adolescent Gynecology.

Almost all surgical procedures have a palliative component to them in that they aim to relieve symptoms of some disease process or injury. Some patients who have life-threatening illnesses or are at the end of their lives may still benefit from surgical procedures, even if the goal of the therapy is not curative. In this chapter, we explore the reasoning prerequisite to offering palliative surgical procedures. The surgeon, the patient, and/or the patient’s surrogate may be confused about the goals of care for palliative surgical therapy. The patient’s goals of care may change as the disease progresses and curative management may transition into palliative management. It is important to explore goals of care at pivotal decision points with the patient, family members, and friends in a multidisciplinary care setting that ideally includes the patient’s primary care physician, relevant specialists, critical care team, and surgeon in order to fully explore all palliative options and set realistic goals and expectations in line with the patient’s wishes and values prior to offering palliative surgical therapy.KeywordsPalliative surgerySurgical ethicsGoals of careOutcome measuresComplicationsSurrogate decision-maker

A variety of health care delivery settings and models have been established in the 1980s. The multidisciplinary setting encourages comanagement and continuity of care, provides convenient consultation and communication, and is cost effective. It stimulates learning, helps to consolidate management strategies, and results in improved quality of care. Therefore, the patient and the provider both benefit from this environment. In 1978, the problem-oriented record keeping system (PORS) was implemented in the eye care service of a Boston neighborhood multidisciplinary health center. It facilitated learning, established guidelines for peer review, and improved patient care by assisting the eye care service to communicate patient problems to the other health center services effectively. We review the background of urban multidisciplinary health care settings and the PORS, as well as present several cases in which optometrists participated in patient comanagement with other health care specialists to develop a comprehensive management plan. The benefits of the multidisciplinary approach to both patients and providers are discussed.

Use of telehealth has grown substantially in recent times due to the COVID-19 pandemic. Remote care services may greatly benefit patients with disabilities; chronic conditions; and neurological, musculoskeletal, and pain disorders, thereby allowing continuity of rehabilitation care, reducing barriers such as transportation, and minimizing COVID-19 exposure. In March 2020, our rehabilitation hospital, Shirley Ryan AbilityLab, launched a HIPAA-compliant telemedicine program for outpatient and day rehabilitation clinics and telerehabilitation therapy programs. The objective of this study was to examine patients' experiences and satisfaction with telemedicine in the rehabilitation physician practice, including novel virtual multidisciplinary evaluations. The present study examines survey data collected from 157 patients receiving telemedicine services at Shirley Ryan AbilityLab from December 2020–August 2021. Respondents were 61.8% female, predominantly White (82.2%) with ages ranging across the lifespan (69.4% over age 50 years). Diagnostic categories of the respondents included: musculoskeletal conditions 28%, chronic pain 22.3%, localized pain 10.2%, neurological conditions 26.8%, and Parkinson's and movement disorders 12.7%. Survey responses indicate that the telemedicine experiences were positive and well received. The majority of participants found these services easy to use, effective, and safe, and were overall satisfied with the attention and care they received from the providers—even for those who had not previously used telehealth. Respondents identified a variety of benefits, including alleviating financial and travel-related burdens. There were no significant differences in telehealth experiences or satisfaction across the different clinical diagnostic groups. Respondents viewed the integrated physician and rehabilitation therapist telehealth multidisciplinary model favorably, citing positive feedback regarding receiving multiple perspectives and recommendations, feeling like an integrated member of their healthcare team, and having a comprehensive, holistic team approach along with effective communication. These findings support that telemedicine can provide an effective care model in physiatry (physical medicine and rehabilitation) clinics, across different neurological, musculoskeletal, and pain conditions and in multidisciplinary team care settings. The insights provided by the present study expand our understanding of patient experiences with remote care frameworks for rehabilitation care, while controlling for institutional variation, and ultimately will help provide guidance regarding longer term integration of telemedicine in physiatry and multidisciplinary care models.

Effect of systematic education courses on rectal cancer treatments in a population

The article presents the author's experience with airway management of 500 children with acute infectious croup and epiglottitis over a 7-year period in a teaching hospital setup. A policy of early elective protective intubation under controlled condition for children with severe croup and epiglottitis, in a multidisciplinary intensive care setting resulted in a satisfactory outcome. Recent developments in the field are discussed; these include non-invasive monitoring, medical treatment options for viral croup with parenteral high dose dexamethasone and nebulized adrenaline, newer broad-spectrum antimicrobials for drug-resistant bacterial infectious and an effective vaccine against Hemophilus influenzae type b. These hold the promise of reducing morbidity and mortality from acute infectious croup syndromes even in situations with limited surgical and monitoring facilities.

Brain metastases (BM) are the most commonly diagnosed secondary brain lesions in adults, influencing these patients' symptoms and treatment courses. With improvements in oncologic treatments, patients with BM are now living longer with their advanced cancers, and issues pertaining to quality of life become more pressing. The American Society of Clinical Oncology has recommended early implementation of palliative care for cancer patients, though incorporation and implementation of palliative and other supportive services in the setting of true multidisciplinary care requires additional attention and research for patients with intracranial metastases. We review the physical, cognitive, and psychosocial challenges patients with BM and their caregivers face during their cancer course as well as the current published research on quality of life metrics relating to this patient population and the diverse roles specialty palliative care, rehabilitation services, and other healthcare providers play in a comprehensive multidisciplinary care model.

The COVID-19 pandemic caused rapid shifts in the workflow of many health services, but evidence of how this affected multidisciplinary care settings is limited. In this data study, we propose a process mining approach that utilises timestamped data from electronic health records to compare care provider patterns across pandemic waves. To investigate healthcare patterns during the pandemic, we collected routine events from Scottish hospital episodes in adults with COVID-19 status, generating treatment logs based on care provider input. Conformance checking metrics were used to select the Inductive Miner infrequent (IMi) algorithm for downstream analysis. Visual diagrams from the discovered Petri Nets indicated interactions on provider- and activity-level data subsets. Measures of “cross-log conformance checking” and graph edit distance (GED) further quantified variation in care complexity in adverse subgroups. Our baseline cohort included 1153 patients with COVID-19 linked to 55,212 relevant care provider events. At the conformance checking stage, the IMi model achieved good log fitness (LF¯=0.95) and generalisation (G¯=0.89), but limited precision (PR¯=0.27) across all granularity levels. More structured care procedures were present in Wave 1, compared to limited multidisciplinary involvement in Wave 2. Care activities differed in patients with extended stay (GED=348,PR¯=0.231vsGED=197,PR¯=0.429 in shorter stays). We demonstrated that process mining can be incorporated to investigate differential complexity in patients with COVID-19 and derive fine-grained evidence on shifts in healthcare practice. Future process-driven studies could use clinical oversight to understand operational adherence and driving factors behind service changes during pressured periods.

BackgroundFunctional gastrointestinal disorders (FGID) are linked to a variety of potential causes, and treatments include reassurance, life-style (including diet), psychological, or pharmacologic interventions.AimsTo assess whether a multidisciplinary integrated treatment approach delivered in a dedicated integrated care clinic (ICC) was superior to the standard model of care in relation to the gastrointestinal symptom burden.MethodsA matched cohort of 52 consecutive patients with severe manifestation of FGID were matched with 104 control patients based upon diagnosis, gender, age, and symptom severity. Patients in the ICC received structured assessment and 12-weeks integrated treatment sessions provided as required by gastroenterologist and allied health team. Control patients received standard medical care at the same tertiary center with access to allied health services as required but no standardized interprofessional team approach. Primary outcome was reduction in gastrointestinal symptom burden as measured by the Structured Assessment of Gastrointestinal Symptoms Scale (SAGIS). Secondary outcome was reduction in anxiety and depressive symptoms as measured by the Hospital Anxiety and Depression Scale (HADS).ResultsMixed models estimated the within ICC change in SAGIS total as −9.7 (95% CI −13.6, −5.8; p < 0.0001), compared with −1.7 (95% CI −4.0, 0.6; p = 0.15) for controls. The difference between groups reached statistical significance, −7.6 (95% CI −11.4, −3.8; p < 0.0001). Total HADS scores in ICC patients were 3.4 points lower post-intervention and reached statistical significance (p = 0.001).ConclusionThis matched cohort study demonstrates superior short-term outcomes of FGID patients in a structured multidisciplinary care setting as compared to standard care.

To demonstrate the multidisciplinary interactions and tools required to effect changes in the processes of care to achieve tight glycemic control (TGC) and reduce deep sternal wound infection (DSWI) rates in patients undergoing cardiac surgery. A retrospective cohort analysis comparing the rate of DSWI before and after implementing a multidisciplinary TGC initiative. A cardiac surgical program in a tertiary care community hospital in New England. A total of 3065 consecutive adult patients undergoing cardiac surgery who were operated on between January 1, 2004, and December 31, 2006. Evidence demonstrating the relationship between hyperglycemia and DSWI was presented to the multidisciplinary group caring for patients undergoing cardiac surgery. In addition, special emphasis was placed on nursing feedback and in-service training. A cumbersome glycemic management text protocol was replaced with a novel color-coded bedside tool (nomogram) to guide the bedside management of hyperglycemia. Subsequently, an algorithm for the transition to a home regimen was developed, which further improved standardization of care and ease of management. Hourly blood glucose level monitoring and the incidence of DSWI. Eighteen months after the new program was initiated, the DSWI rate decreased by more than 60% from 2.6% to 1.0%, when compared with the preceding 18 months (P < .001). A TGC program using a novel tool in a multidisciplinary setting was successfully and safely established, resulting in sustained improvement in the DSWI rate.