A two-echelon responsive health analytic model for triggering care plan revision in geriatric care management

Due to the increasing ageing population, how can caregivers effectively provide long-term care services to meet the older adults’ needs with finite resources is emerging. In addressing this issue, nursing homes are striving to adopt smart health with the internet of things and artificial intelligence to improve the efficiency and sustainability of healthcare. This study proposed a two-echelon responsive health analytic model (EHAM) to deliver appropriate healthcare services in nursing homes under the Internet of Medical Things environment. A novel care plan revision index is developed using a dual fuzzy logic approach for multidimensional health assessments, followed by care plan modification using case-based reasoning. The findings reveal that EHAM can generate patient-centred long-term care solutions of high quality to maximise the satisfaction of nursing home residents and their families. Ultimately, sustainable healthcare services can be within the communities.

Dosimetric Evaluation of Oesophagus in Hypofractionated Supraclavicular Nodal Irradiation in Breast Cancer - A Retrospective Observational Study in a Tertiary Care Cancer Centre in Alappuzha, Kerala

BACKGROUND Acute esophagitis (AE) is a common toxicity seen in patients undergoing radiotherapy (RT) for breast cancer, which can affect their quality of life. Thus, majority of our patients receiving hypo fractionated dose of 40 Gy in 15 fractions were having AE. We conducted this study to evaluate the dosimetric parameters of oesophagus and correlate with published literature. METHODS Treatment plans of 80 post mastectomy patients who underwent radiotherapy for carcinoma of breast (Ca breast) with a dose of 40 Gy in 15 fractions to the chest wall along with supra clavicular fossa (SCF) were selected. Out of these, 44 patients (22 each in right and left side) were simulated in neck straight position and 36 in neck tilted position (18 each in right and left side). The oesophageal volume was contoured in already executed plans from the inferior border of cricoid cartilage to the inferior border of the SCF planning target volume (PTV). No plan modification was done after contouring the oesophagus. Dosimetric parameters like the maximum dose (Dmax) and mean dose (Dmean) to oesophagus, volume of oesophagus receiving ≥ 5 Gy (V5), ≥ 10 Gy (V10), ≥ 15 Gy (V15), ≥ 20 Gy (V20), ≥ 25 Gy (V25), ≥ 30 Gy (V30) were derived from dose volume histogram (DVH) data and analysed. RESULTS Dmean in straight neck group irrespective of side was 18.57 (± 7.30) Gy and in tilted neck 22.94 (± 9.53,) Gy, P = 0.023. Subgroup analysis shows Dmean was significantly high in patients with left sided disease than those with right sided disease (24.10 vs. 13.03, P = 0.00) in the straight neck cases. In the neck tilted group there was a nonsignificant increase in Dmean in left sided cases (25.36 vs. 20.53, P = 0.13). CONCLUSIONS Evaluation of oesophageal dosimetric parameters in hypofractionated dose showed that DmeanEQD2 was within the values of published studies in conventional fractionation. KEYWORDS Oesophageal Dosimetric Parameters, Breast Cancer

Infection Control and Modified Workflow Strategies in Radiation Oncology Department during COVID 19 Crisis: An Institutional Experience

Purpose: To build safe environment for cancer fighters and radiation personnel during COVID-19 pandemic by focusing on infection control, workflow and radiotherapy dose schedules modification strategies in radiation oncology departments. Material and Methods: A meeting was called post lock down in radiation oncology department to prepare infection control policies and workflow strategies in time of COVID-19 Pandemic.Results: Strategies and policies were formed during COVID-19 crises taking following points into consideration 1) Infection control policies 2) CT simulation policies 3) Day care admission and chemotherapy administration policies 4) Radiation treatment plan modification and delivery strategies 5) Brachytherapy delivery strategies.Conclusion: Management of cancer patients is an issue running parallel to the present condition of COVID-19 pandemic. Further randomized trial on hypofractionated radiotherapy schedules should be encouraged. Positivity, awareness and systematic approach are most important step in balancing the current scenario.

Re-audit of use of seclusion in a tier 4 adolescent psychiatric intensive care unit

AimsTo re-audit seclusion practices within a Tier 4 Adolescent PICU provision in London, originally audited in 2018. To ensure restrictive practices are only used in exceptional circumstances for short term risk management. To evaluate whether practice has improved following introduction of incidence reduction strategies and identify any further areas of development.BackgroundThis Tier 4 Adolescent PICU provides treatment of up to 16 high risk and unwell adolescents with severe and enduring mental health illnesses. Seclusion should be a short term risk management strategy with subsequent review of the care plan and treatment. It should be used for the shortest time possible. Following the audit in 2018, three strategies were implemented to reduce restrictive practice: (1) daily nursing safety huddles, (2) weekly Incidence Reduction meetings, and (3) ongoing QI project on restrictive practice.MethodData were collected from all patients requiring seclusion between January and December 2019 (n = 18), which included 46 incidents. Data were collected from RiO computer records, extracting details of patient demographics, reasons and context of seclusion, risk reduction steps prior, length of seclusion, monitoring, and modifications to care plans.ResultAverage length of stay in seclusion was 20h, reduced from 30h previously. Over half of patients requiring seclusion had symptoms of psychosis, consistent with the original audit. Majority of incidents involved assault to staff (80.4%) as indication for seclusion, compared to 50% previously. In 58.7% of cases, verbal de-escalation was followed by further risk reduction with oral medication. Overall, rapid tranquillisation was required in 45.7% of incidents. Restraint was used in 84.8% of incidents, always in combination with at least one other management strategy.Just under half of seclusions were monitored and documented in line with Trust guidelines, however, there was significant improvement in documentation of consultant reviews within 24h from under 70% to over 90%. Care plan modification rates improved from 63% to over 95%.ConclusionMajority of seclusion incidents were due to violent acts by young people presenting with psychotic features/disorder. This reflects the complex nature of psychosis and the substantial need for research to reduce restrictive practice in such cases.Ongoing review of data relating to seclusion will continue to inform and improve practice. This re-audit demonstrates improvement in various areas after implementation of strategies to reduce restrictive practice – importantly, average time in seclusion, documentation of 24 hour consultant reviews and focus on non-pharmacological risk reduction approaches in care plan modifications.

Takt Planning in Apartment Building Renovation Projects

Takt production has been of great interest in construction during the last few years. In this research, a case study was carried out to demonstrate how the scheduling of an apartment building renovation project that utilizes takt production can be done. Furthermore, the study defines what clarifications should be made into the existing takt production models in the context of apartment building renovation projects, and it also explains why. Based on the study, adhering to a uniform production rate is challenging in apartment renovation projects. Therefore, a total of five clarifications to existing takt production methods are suggested. (1) Production with short takt requires a highly detailed definition of tasks in order to avoid ambiguousness. (2) Some tasks carried out in takt areas may have to be excluded from takt production. (3) The sensitivity of a created takt schedule should be evaluated, and buffers should be added accordingly. (4) Emphasis must be put on coordinating takted and non-takted tasks. (5) Takt plan modification during production requires effective procedures, since there is little time to react.

Pharmacist value-added to neuro-oncology subspecialty clinics: A pilot study uncovers opportunities for best practices and optimal time utilization

Purpose To evaluate neuro-oncology clinician time utilization for medication management and identify a cost beneficial role for integration of a dedicated pharmacy specialists. Methods A pharmacist was temporarily integrated into a neuro-oncology clinic for a 30-day period to evaluate the clinical practice and perform a 14-day clinical chart evaluation and patient interactions as part of a single institutional exploratory analysis. The pharmacist completed screenings for drug-drug interactions, new therapies, medication reconciliation, and advanced interventions as part of a collaborative practice agreement for pharmacist autonomy. Pharmacist time spent was calculated and documented within the patient encounters to support physician decision-making. A comparative estimate of pharmacist versus physician time utilization and cost for each was completed to derive a savings analysis for integration of a dedicated clinic pharmacist. Result During the 14-day clinical assessment, the pharmacist completed 147 encounters with 338 interventions. Of the encounters, 90% (n = 132) were higher complexity requiring plan modification, and approximately 48% (n = 162) of all interventions required ≥10 minutes of the pharmacist’s time. Physician non-patient-facing time devoted to medication tasks was 5-hours weekly (0.125 FTE, full time equivalents), an estimated direct salary cost of $937/week ($45,000 yearly). Hire of a part-time pharmacist at 0.50 FTE would cover the clinical need with supported documentation and medication monitoring at a cost of $45,000/year. Conclusion Defining the roles for dedicated neuro-oncology clinic pharmacists allows for cost-savings through re-allocation of physician time and improves subspecialty clinic operations as well as patient care.

MRI appearance change during stereotactic radiotherapy for large brain metastases and importance of treatment plan modification during treatment period

Purpose We aimed to evaluate the magnetic resonance imaging (MRI) appearance changes during stereotactic radiotherapy (SRT) for large sized brain metastases, and analyze the lesions necessitating treatment plan modification. Materials and methods A total of 23 patients (27 lesions, >2 cm in tumor diameter) underwent SRT and all lesions were evaluated the appearance changes which had the necessity of the treatment plan modification. The appearance change of tumor during SRT was evaluated using gadolinium-enhanced MRI. The reasons of the modification were classified into tumor reduction, tumor enlargement, displacement, and shape change. Results Among the 27 lesions, 55.6% required the treatment plan modification. The reasons were tumor reduction in six lesions, tumor enlargement in three lesions, displacement in three lesions, and shape change in three lesions. The planning target volume (PTV) size changed up to 43.0% and the shift of center of PTV was a maximum of 1.7 mm. The pathological status (adenocarcinoma vs others) and timing of steroid administration (prior vs after SRT start) were the predictive factors of tumor changes required the modification. Conclusions As tumor changes might occur even during short period of SRT, the treatment plan evaluation and modification were important in SRT for large brain metastases.