Developing Integrated Clinical Pathways for the Management of Clinically Severe Adult Obesity: a Critique of NHS England Policy.

PURPOSE OF THE REVIEW: Pathways for obesity prevention and treatment are well documented, yet the prevalence of obesity is rising, and access to treatment (including bariatric surgery) is limited. This review seeks to assess the current integrated clinical pathway for obesity management in England and determine the major challenges. RECENT FINDINGS: Evidence for tier 2 (community-based lifestyle intervention) and tier 3 (specialist weight management services) is limited, and how it facilitates care and improve outcomes in tier 4 remains uncertain. Treatment access, rigidity in pathways, uncertain treatment outcomes and weight stigma seems to be major barriers to improved care. More emphasis must be placed on access to effective treatments, treatment flexibility, addressing stigma and ensuring treatment efficacy including long-term health outcomes. Prevention and treatment should both receive significant focus though should be considered to be largely separate pathways. A simplified system for weight management is needed to allow flexibility and the delivery of personalized care including post-bariatric surgery care for those who need it.

COVID-19 and medical litigation: More than just the obvious.

COVID-19 has massively changed the health landscape around the world. Wide-ranging changes to healthcare delivery have occurred, especially in hospitals and EDs. Health services have made local decisions about care pathways, in some cases deviating from what would, until recently, have been considered widely accepted care. These changes bring with them new medicolegal risk for clinicians. In Australia, civil liability Acts provide protection for professionals when the criterion of having undertaken 'competent' practice that would be 'widely accepted' 'in the circumstances' is met. There is doubt how courts, and the medical experts who advise them, will evaluate clinical care provided during the pandemic when health services have developed local care pathways and there is no nationally accepted standard.

Human Trafficking in the Emergency Department: Improving Our Response to a Vulnerable Population.

Human trafficking is a human rights violation affecting millions worldwide. Victims may go unrecognized during their emergency department (ED) visit, and may lose the opportunity to address their complex needs. Using a published toolkit based on existing guidelines and recommendations from experts, and models from other centers, we describe the implementation of an ED response protocol. In following the recommendations of the toolkit, we began with attempts to fully understand the local human trafficking problem and then networked with those working in anti-trafficking efforts. Collaboration with other specialties is highlighted as a key part of this process. Building upon the knowledge gained from these steps, we were able to develop a concise protocol to guide members of our department in more effectively caring for known or suspected victims of human trafficking. The first section of the protocol addresses ways in which providers can identify at-risk patients through both screening questions and general observations. Interviewing techniques are outlined with an emphasis on patient-centered and trauma-informed care. Additionally, the protocol discusses physician responsibility in documenting encounters and legal reporting, which may vary depending on location. We stress the importance of meeting the needs of the patient while prioritizing the safety of all involved. Additionally, the protocol provides a list of resources for the patient beyond medical care such as emergency housing, legal assistance, and food pantries. The overall purpose of this protocol is to provide coordinated response so that all providers may be consistent in caring for this vulnerable population.

Beecher Dépassé: Fifty Years of Determining Death, Legally.

Five decades ago, Henry Knowles Beecher, a renowned professor of research anesthesiology, sought to solve a problem created by modern medicine. The solution proposed by Beecher and his colleagues on the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death proved very influential.1 Indeed, other contemporaneous medical developments magnified its significance yet also made the solution it offered somewhat problematic. As we mark this fiftieth anniversary, at a time when concerns about the conceptual model on which its recommendations rested are being voiced by critics from medicine as well as philosophy, it is worthwhile to view the committee's report in relation to the problem that prompted its existence as well as the one to which it was quickly applied.

[Care and restraint, when the law questions nursing practice]. / Soins sous contrainte, quand le droit interroge la pratique.

With the reforms of 2011 and 2013 relating to psychiatric hospitalisation, raises the question of the suitability of modern psychiatric practice with regard to a person's recognised principles and basic rights. Achieving a balance is difficult and the Constitutional Council has joined the debate, bringing to an end any idea of compromise between safety and freedom. A decision which was made as a result of a clarification of certain regulations which have proved controversial from the point of view of individual liberties.

Guideline for obtaining valid consent for gastrointestinal endoscopy procedures.

Much has changed since the last guideline of 2008, both in endoscopy and in the practice of obtaining informed consent, and it is vital that all endoscopists who are responsible for performing invasive and increasingly risky procedures are aware of the requirements for obtaining valid consent. This guideline is restricted to GI endoscopy but we cover elective and acute or emergency procedures. Few clinical trials have been carried out in relation to informed consent but most areas are informed by guidance from the General Medical Counsel (GMC) and/or are enshrined in legislation. Following an iterative voting process a series of recommendations have been drawn up that cover the majority of situations that will be encountered by endoscopists. This is not exhaustive and where doubt exists we have described where legal advice is likely to be required. This document relates to the law and endoscopy practice in the UK-where there is variation between the four devolved countries this is pointed out and endoscopists must be aware of the law where they practice. The recommendations are divided into consent for patients with and without capacity and we provide sections on provision of information and the consent process for patients in a variety of situations. This guideline is intended for use by all practitioners who request or perform GI endoscopy, or are involved in the pathway of such patients. If followed, we hope this document will enhance the experience of patients attending for endoscopy in UK units.

Internal Controlling of a Radiology Department.

Caused by legal reform initiatives there is a continuous need to increase effectiveness and efficiency in hospitals and surgeries, and thus to improve processes.Consequently the successful management of radiological departments and surgeries requires suitable structures and optimization processes to make optimization in the fields of medical quality, service quality and efficiency possible.In future in the DRG System it is necessary that the organisation of processes must focus on the whole clinical treatment of the patients (Clinical Pathways). Therefore the functions of controlling must be more established and adjusted. On the basis of select Controlling instruments like budgeting, performance indicators, process optimization, staff controlling and benchmarking the target-based and efficient control of radiological surgeries and departments is shown.

[Exercise scenario of a highly contagious, life-threatening disease in intercontinental aviation : a case report in the context of the International Health Regulations (IHR)]. / Übungsszenario für eine hochkontagiöse, lebensbedrohliche Erkrankung in der interkontinentalen Personenluftfahrt : Eine Kasuistik vor dem Hintergrund der internationalen Gesundheitsvorschriften (IGV).

BACKGROUND: The International Health Regulations (IHR) 2005 were conformed to German law on July 20, 2007 and described in detail by the Implementing Act (IHR DG). According to these legal bases, "designated airports" must maintain special capacities for protection against health threats, and are also responsible for performing regular IHR exercises. OBJECTIVES: Representation of the optimization of established operational concepts of various professions to manage infectious biological threats without obstruction of international travel, and mediation of experience to IHR professionals. MATERIALS AND METHODS: An exercise based on the case scenario of a travel-related febrile illness was performed at Munich International Airport on November 11, 2013. Preparations took 6 months and the exercise itself lasted nearly 12 h. The follow-up lasted an additional 9 months. A qualitative and quantitative evaluation of the exercise was completed. RESULTS: From an Individual Medicine and Public Health perspective, modular work structures and risk communication functioned adequately. The medical examination of passengers was also well managed. Areas requiring further optimization included arrival/departure times of external actors, transport of the index patient to hospital and protective measures for individual participants. Overall, a defined biological threat scenario representing a double infection with two highly pathogenic germs was handled satisfactorily without affecting international air travel. CONCLUSIONS: Modular supply components are an effective and forward-looking means in protection against threats occurring at airports. Key success factors include sufficient staff mobility, immediate self-protection of actors involved, effective risk communication and a strong overall coordination and monitoring of the situation.

[DEVELOPMENT OF THE LOCAL CLINICAL PATHWAY "PREVENTION OF CARDIOVASCULAR DISEASE" (SCIENTIFIC STATEMENT AND PRACTICAL APPROACH)].

An overview of scientific data on current approaches to the prevention of cardiovascular diseases has been exposed. The results of proceedings on development of the local clinical pathway "Prevention of cardiovascular disease" in the State Institution of Science "Research and Practical Center of Preventive and Clinical Medicine" State Administrative Department has been generalized.

Ethics and end of life care: the Liverpool Care Pathway and the Neuberger Review.

The Liverpool Care Pathway for the Dying has recently been the topic of substantial media interest and also been subject to the independent Neuberger Review. This review has identified clear failings in some areas of care and recommended the Liverpool Care Pathway be phased out. I argue that while the evidence gathered of poor incidences of practice by the Review is of genuine concern for end of life care, the inferences drawn from this evidence are inconsistent with the causes for the concern. Seeking to end an approach that is widely seen as best practice and which can genuinely deliver high quality care because of negative impressions that have been formed from failing to implement it properly is not a good basis for radically overhauling our approach to end of life care. I conclude that improvements in training, communication and ethical decision-making, without the added demand to end the Liverpool Care Pathway, would have resulted in a genuine advance in end of life care.

Equity in cancer care: pathways, protocols, and guidelines.

The quality of patient care varies based on numerous factors, such as health care setting, geographic location, access to medications, insurance coverage, and treatment protocols. Recently, the issue of whether use of clinical pathways can reduce costs and inappropriate variability in care has been the subject of much debate. As clinical treatment guidelines and pathways are increasingly deployed in oncology practice, they have a growing impact on the quality of treatment and how it is delivered. To fulfill the current need to discuss the use of pathways and clinical treatment guidelines in oncology and to address how patient care is impacted by their use, the National Comprehensive Cancer Network convened the NCCN Oncology Policy Summit: Equity in Cancer Care-Pathways, Protocols, and Guidelines. The summit was a forum to discuss the use and implementation of pathways, including how much flexibility pathways should allow in care, pathways' impact on public and private health insurance benefit design, what data is used to select pathway regimens and protocols, and ultimately what impact pathways may have on variation in care. The use and implementation of clinical treatment guidelines in practice was also explored from a variety of perspectives.

The Critical Path Institute's approach to precompetitive sharing and advancing regulatory science.

Many successful large industries, such as computer-chip manufacturers, the cable television industry, and high-definition television developers,(1) have established successful precompetitive collaborations focusing on standards, applied science, and technology that advance the field for all stakeholders and benefit the public.(2) The pharmaceutical industry, however, has a well-earned reputation for fierce competition and did not demonstrate willingness to share data or knowledge until the US Food and Drug Administration (FDA) launched the Critical Path Initiative in 2004 (ref. 3).

[Implementing palliative care for newborns in various care settings. Part 3 of "Palliative care in the neonatal period"]. / La mise en oeuvre pratique des soins palliatifs dans les différents lieux de soins : 3(e) partie des réflexions et propositions autour des soins palliatifs en période néonatale.

Palliative care in newborns may take place in the delivery room and then continued either in maternity wards or in the neonatal unit. For babies developing a chronic condition, going home may be advantageous. The population concerned includes babies born with a severe intractable congenital malformation and certain extremely preterm newborn babies at the limits of viability. Care procedures as well as withholding and withdrawing treatments are reviewed.

The misuse of clinical paths as an instrument for funding inpatient care in Bulgaria.

Clinical paths in Bulgaria are used not as a method for quality assessment, but as an instrument to fund hospitals. Their use and incompleteness cause limited access of all Bulgarian citizens to the international treatment guidelines. That way quality of treatment worsens and mortality increases. The Bulgarian system of regulated medical guidelines by all therapeutic and surgical lines still suffers many deficiencies. The National Health Insurance Fund should use the system of clinical paths for quality control as well.

End of life care pathways: ethical and legal principles.

Myths have developed surrounding the law and ethical principles in end of life care, which can make care provision at the end of life complex and fraught with potential dilemmas. This article examines three of the most common myths related to the provision of palliative care and highlights their inadequacy when set against the ethical and legal principles on which end of life care pathways are based.