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BACKGROUND: NHS staff recruitment and retention have failed to keep pace with service demands and workforce burn-out is of significant concern. This quality improvement project (QIP) aimed to increase staff time for patient facing care through reducing duplication of hospital board rounds within a 36-bedded NHS inpatient geriatric ward. INTERVENTION: Thirty-minute board rounds were reduced from twice daily (Monday-Friday) at 08:30 hours and midday to once daily at midday with the aim of freeing up staff time for patient care. A multidisciplinary team (MDT) safety briefing at 08:30 hours lasting 5-10 min was implemented to enable review of shift pressures and identification of patients who are unwell, newly admitted or due for discharge. Safety briefing format was amended to further support staff prioritisation. METHODS: This QIP was underpinned by the model for improvement, using Plan-Do-Study-Act cycles. Data were collected through a staff questionnaire alongside calculation of staff time spent at board rounds and safety huddles. Staff verbal feedback and questionnaire results were also used to improve and modify process'. Patient discharge data were collated via trust metrics as a balancing measure. RESULTS: Through board round modification, 25 hours of MDT time was saved each week, with all responding staff reporting increased time for patient facing care following QIP implementation. >85% of questionnaire respondents agreed that board round changes resulted in improvement. Balancing measures collected as part of the project also revealed an increase in weekly ward discharges from an average of 15.75-17.5 confirming no negative impact on patient flow following board round amendments. CONCLUSION: While significant staffing shortages continue, local innovations focused on staff time may have the potential to support effective use of limited resources.

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OBJECTIVE: Maximal safe resection is the goal of surgical treatment for high-grade glioma (HGG). Deep-seated hemispheric gliomas present a surgical challenge due to safety concerns and previously were often considered inoperable. The authors hypothesized that use of tubular retractors would allow resection of deep-seated gliomas with an acceptable safety profile. The purpose of this study was to describe surgical outcomes and survival data after resection of deep-seated HGG with stereotactically placed tubular retractors, as well as to discuss the technical advances that enable such procedures. METHODS: This is a retrospective review of 20 consecutive patients who underwent 22 resections of deep-seated hemispheric HGG with the Viewsite Brain Access System by a single surgeon. Patient demographics, survival, tumor characteristics, extent of resection (EOR), and neurological outcomes were recorded. Cannulation trajectories and planned resection volumes depended on the relative location of white matter tracts extracted from diffusion tractography. The surgical plans were designed on the Brainlab system and preoperatively visualized on the Surgical Theater virtual reality SNAP platform. Volumetric assessment of EOR was obtained on the Brainlab platform and confirmed by a board-certified neuroradiologist. RESULTS: Twenty adult patients (18 with IDH-wild-type glioblastomas and 2 with IDH-mutant grade IV astrocytomas) and 22 surgeries were included in the study. The cohort included both newly diagnosed (n = 17; 77%) and recurrent (n = 5; 23%) tumors. Most tumors (64%) abutted the ventricular system. The average preoperative and postoperative tumor volumes measured 33.1 ± 5.3 cm3 and 15.2 ± 5.1 cm3, respectively. The median EOR was 93%. Surgical complications included 2 patients (10%) who developed entrapment of the temporal horn, necessitating placement of a ventriculoperitoneal shunt; 1 patient (5%) who suffered a wound infection and pulmonary embolus; and 1 patient (5%) who developed pneumonia. In 2 cases (9%) patients developed new permanent visual field deficits, and in 5 cases (23%) patients experienced worsening of preoperative deficits. Preoperative neurological or cognitive deficits remained the same in 9 cases (41%) and improved in 7 (32%). The median overall survival was 14.4 months in all patients (n = 20) and in the newly diagnosed IDH-wild-type glioblastoma group (n = 16). CONCLUSIONS: Deep-seated HGGs, which are surgically challenging and frequently considered inoperable, are amenable to resection through tubular retractors, with an acceptable safety profile. Such cytoreductive surgery may allow these patients to experience an overall survival comparable to those with more superficial tumors.

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Background Magnetic resonance imaging (MRI)-guided laser interstitial thermal therapy (LITT) is a minimally invasive treatment modality that has been gaining traction in neuro-oncology. Laser ablation is a particularly appealing treatment option when eloquent neurologic function at the tumor location precludes conventional surgical excision. Although typically performed under general anesthesia, LITT in awake patients may help monitor and preserve critical neurologic functions. Objective To describe intraoperative workflow and clinical outcomes in patients undergoing awake laser ablation of brain tumors. Methods We present a cohort of six patients with tumors located in eloquent brain areas that were treated with awake LITT and report three different workflow paradigms involving diagnostic or intraoperative MRI. In all cases, we used NeuroBlate® (Monteris Medical, Plymouth, MN) fiberoptic laser probes for stereotactic laser ablation of tumors. The neurologic status of patients was intermittently assessed every few minutes during the ablation. Results The mean preoperative tumor volume that was targeted was 12.09 ± 3.20 cm3, and the estimated ablation volume was 12.06 ± 2.75 cm3. Performing the procedure in awake patients allowed us close monitoring of neurologic function intraoperatively. There were no surgical complications. The length of stay was one day for all patients except one. Three patients experienced acute or delayed worsening of pre-existing neurologic deficits that responded to corticosteroids. Conclusion We propose that awake LITT is a safe approach when tumors in eloquent brain areas are considered for laser ablation.

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With an ageing population and increasing focus on community care, this study aimed to explore the experiences of community nurses in assessing frailty and planning interventions around frailty. Six community nurses were recruited for face-to-face semi-structured interviews as part of this qualitative study which was underpinned by a competence framework ( Royal College of Nursing, 2009 ). Thematic analysis was used and frailty was identified as an emerging topic within practice. Participants discussed several aspects associated with frailty; however, some uncertainty around the concept of frailty and its definition was noted, particularly for staff who had received limited frailty training. Participants had a growing awareness of frailty in practice, but challenges-including time constraints and staffing within some roles, a perception of limited services to support older people, and for some a lack of confidence and training-presented barriers to frailty assessment. The Rockwood frailty scale was used by participants within practice, but evidence suggested it was felt to lack validity within the community setting.

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The medical sector presents a unique opportunity for identification and service to victims of human trafficking. In this article, we describe local and site-specific efforts to develop an intervention tool to be used in an urban hospital's emergency department in the midwestern United States. In the development of our tool, we focused on both identification and intervention to assist trafficked persons, through a largely collaborative process in which we engaged local stakeholders for developing site-specific points of intervention. In the process of developing our intervention, we highlight the importance of using existing resources and services in a specific community to address critical gaps in coverage for trafficked persons. For example, we focus on those who are victims of labor trafficking, in addition to those who are victims of sex trafficking. We offer a framework informed by rights-based approaches to anti-trafficking efforts that addresses the practical challenges of human trafficking victim identification while simultaneously working to provide resources and disseminate services to those victims.

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