The antimicrobial susceptibilities of 100 clinical isolates ofPseudononas aeruginosa to gentamici... more The antimicrobial susceptibilities of 100 clinical isolates ofPseudononas aeruginosa to gentamicin, amikacin, tobramycin, ticarcillin, piperacillin, and ceftazidime were determined by using the Sceptor system (BBL Microbiology Systems, Cockeysville, Md.), and the results were compared with those obtained using the National Committee for Clinical Laboratory Standards reference agar dilution method. Excellent correlation was observed for the aminoglycosides, with >95% agreement within 1 doubling dilution of the reference agar dilution MIC, while ticarcillin and piperacillin showed lower percent agreement values of 91 and 88%,
Rationale, Aims, and ObjectivesHealthLinks: Chronic Care is a state‐wide public hospital initiati... more Rationale, Aims, and ObjectivesHealthLinks: Chronic Care is a state‐wide public hospital initiative designed to improve care for cohorts at‐risk of potentially preventable hospitalizations at no extra cost. MonashWatch (MW) is an hospital outreach service designed to optimize admissions in an at‐risk cohort. Telehealth operators make regular phone calls (≥weekly) using the Patient Journey Record System (PaJR). PaJR generates flags based on patient self‐report, alerting to a risk of admission or emergency department attendance. ‘Total flags’ of global health represent concerns about self‐reported general health, medication, and wellness. ‘Red flags’ represent significant disease/symptoms concerns, likely to lead to hospitalization.MethodsA time series analysis of PaJR phone calls to MW patients with ≥1 acute non‐surgical admissions in a 20‐day time window (10 days pre‐admission and 10 days post‐discharge) between 23 December 2016 and 11 October 2017. Pettitt's hypothesis‐testing ...
Background: MonashWatch is a telehealth public hospital outreach pilot service as a component of ... more Background: MonashWatch is a telehealth public hospital outreach pilot service as a component of the Government of Victoria's statewide redesign initiative called HealthLinks: Chronic Care. Rather than only paying for hospitalizations, projected funding is released earlier to hospitals to allow them to reduce hospitalization costs. MonashWatch introduced a web-based app, Patient Journey Record System, to assess the risk of the journeys of a cohort of patients identified as frequent admitters. Telecare guides call patients using the Patient Journey Record System to flag potential deterioration. Health coaches (nursing and allied health staff) triage risk and adapt care for individuals. Objective: The aim was a pragmatic controlled evaluation of the impact of MonashWatch on the primary outcome of bed days for acute nonsurgical admissions in the intention-to-treat group versus the usual care group. The secondary outcome was hospital admission rates. The net promoter score was used to gauge satisfaction. Methods: Patients were recruited into an intention-to-treat group, which included active telehealth and declined/lost/died groups, versus a systematically sampled (4:1) usual care group. A rolling sample of 250-300 active telehealth patients was maintained from December 23, 2016 to June 23, 2019. The outcome-mean bed days in intervention versus control-was adjusted using analysis of covariance for age, gender, admission type, and effective days active in MonashWatch. Time-series analysis tested for trends in change patterns. Results: MonashWatch recruited 1373 suitable patients who were allocated into the groups: usual care (n=293) and intention-to-treat (n=1080; active telehealth: 471/1080, 43.6%; declined: 485, 44.9%; lost to follow-up: 178 /1080, 10.7%; died: 8/1080, 0.7%). Admission frequency of intention-to-treat compared to that of the usual care group did not significantly improve (P=.05), with a small number of very frequent admitters in the intention-to-treat group. Age, MonashWatch effective days active, and treatment group independently predicted bed days. The analysis of covariance demonstrated a reduction in bed days of 1.14 (P<.001) in the intention-to-treat group compared with that in the usual care group, with 1236 bed days estimated savings. Both groups demonstrated regression-to-the-mean. The downward trend in improved bed days was significantly greater (P<.001) in the intention-to-treat group (Sen slope-406) than in the usual care group (Sen slope-104). The net promoter score was 95% in the active telehealth group compared with typical hospital scores of 77%. Conclusions: Clinically and statistically meaningful reductions in acute hospital bed days in the intention-to-treat group when compared to that of the usual care group were demonstrated (P<.001), although admission frequency was unchanged with more short stay admissions in the intention-to-treat group. Nonrandomized control selection was a limitation. Nonetheless, MonashWatch was successful in the context of the HealthLinks: Chronic Care capitation initiative and is expanding.
Modern healthcare has delivered achievements that no one could have anticipated prior to World Wa... more Modern healthcare has delivered achievements that no one could have anticipated prior to World War II, largely driven by science in both discovery and application mode. Why then do so many now feel that modern healthcare is failing to deliver on the unwritten promise that as each year unfolds greater gains will be delivered than in the year before? Design and systems thinking offers an opportunity for healthcare workers to co-design new ways of organising and delivering services. First, however, healthcare workers will need to learn new technical skills and gain a greater appreciation of the sociotechnical construction of heath service delivery as well as receive instruction in new methods so that these new ways of being and organising service delivery can be brought into effect. This will have profound implications for existing service delivery models and organisations. This chapter outlines and illustrates some approaches that can and are being taken to train and educate the healthcare workforce to design and bring into being the healthcare organisations and systems for the future. It is not clear which clinicians and students are best suited to learn and apply the methods and mindsets of design and systems thinking, nor which settings and contexts are best suited to the application of these methods. Research on the teaching and learning experience will guide further developments in the teaching of design and systems thinking for healthcare professionals.
Background: Standardised structure and content of interdisciplinary medical ward rounds can promo... more Background: Standardised structure and content of interdisciplinary medical ward rounds can promote patient safety and patient-centred teamwork. Aims: This study aimed to evaluate interdisciplinary ward rounds using a Structured Interdisciplinary Bedside Rounding (SIBR). Methods: Multi-method, repeat measures with a non-equivalent control group. Non-participant observations were, collected at one and six months, on an intervention ward that introduced SIBR and a control ward that continued traditional rounds. F ocus group and survey data were also collected on the intervention ward. Participants were clinicians (medicine, nursing and allied health) working in two general medicine wards at a tertiary hospital in Melbourne, Australia.
International Journal of Integrated Care, Aug 8, 2019
Suggestions for future research: Research into the improvement in the nexus of Big Data predictiv... more Suggestions for future research: Research into the improvement in the nexus of Big Data predictive analytics and anticipatory care in the quest to intervene in the emergent observable state of a person's health to improve health and better utilize health care resources.
Australia, like most other countries, has grown up with susceptibility testing in many forms, sub... more Australia, like most other countries, has grown up with susceptibility testing in many forms, subject to international forces and local whims. Consistent with its history, ELSEVIER
BACKGROUND Monash Watch (MW) aims to reduce avoidable hospitalizations in a cohort above a risk ‘... more BACKGROUND Monash Watch (MW) aims to reduce avoidable hospitalizations in a cohort above a risk ‘threshold’ identified by HealthLinks Chronic Care (HLCC) algorithms using personal, diagnostic, and service data, excluding surgical and psychiatric admissions. MW conducted regular patient monitoring through outbound phone calls using the Patient Journey Record System (PaJR). PaJR alerts are intended to act as a self-reported barometer of health perceptions with more alerts per call indicating greater risk of Potentially Preventable Hospitalizations (PPH) and Post Hospital Syndrome (PHS). Most knowledge of PPH and PHS occurs at a macro-level with little understanding of fine-grained dynamics. OBJECTIVE To describe patterns of self-reported concerns and self-rated health 10 days before and after acute hospital admission in the telehealth intervention cohort of MonashWatch in the context of addressing PPH and PHS. METHODS Participants: 173 who had an acute admission of the of the 232 HLCC cohort with predicted 3+ admissions/year, in MW service arm for &amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;40 days. Measures: Self-reported health and health care status in 764 MW phone call records which were classified into Total Alerts (all concerns - self-reported) and Red Alerts (concerns judged to be higher risk of adverse outcomes/admissions -acute medical and illness symptoms). Acute (non-surgical) admissions from Victorian Admitted Episode database. Analysis: Descriptive Timeseries homogeneity metrics using XLSTAT. RESULTS Self-reported problems (Total Alerts) statistically shifted to a higher level 3 days before an acute admission and stayed at a high level for the 10 days post discharge; reported acute medical and illness symptoms (Red Alerts) increased 1 day prior to admission and but remained at a higher level than before admission. Symptoms of concern did not change before admission or after discharge. Self-rated health and feeling depressed were reported to worsen 5 days post discharge. Patients reported more medication changes up to 2 days before acute admission. CONCLUSIONS These descriptive findings in a cohort of high risk individuals suggest a prehospital phase of what is termed PHS, which persisted on discharge and possibly worsened 5 days after discharge with worse self-rated health and depressive symptoms. Further research is needed. The role and place of community and hospital in such a cohort needs further investigation and research into PPH and PHS.
Hospital readmissions are the consequence of an individual unstable health journeys in the contex... more Hospital readmissions are the consequence of an individual unstable health journeys in the context of their local health services and community configurations. The Patient Journey Record System (PaJR) has developed a conversational approach with care guides and clinician coaches who support such health journeys irrespective of condition and location.
International Journal of Integrated Care, Feb 26, 2021
Post-hospital syndrome (PHS) is a state of increased vulnerability to ill-health in the 10 days p... more Post-hospital syndrome (PHS) is a state of increased vulnerability to ill-health in the 10 days post discharge, but what health states lead to admission? This study investigates health profiles/symptoms 10 days before and after acute medical admissions in Monash Watch (MW)-a hospital telehealth pilot to optimize avoidable hospitalizations in those with predicted risk of 3+ hospitalizations using hospital algorithms. Methods: Telecare guides conduct regular patient outbound phone calls. More alerts per call indicate greater risk. Total alerts represent general health, psychosocial and care issues. Red alerts represent medical symptoms and illness. Design: A cohort study of MW subgroup of 103 admitted patients (total sample 233). Data: Self-reported health profiles and alerts in 764 MW phone call records and acute (nonsurgical) admissions data over a 6 month period Analytics: Descriptive time series using homogeneity metrics with XLSTAT. Results: Fair to poor self-rated health was reported 10 days before until 5 days after admission. Moderate to severe pain and feeling depressed was reported from 10 days before to 10 days after admissions. Total alerts statistically increased 3 days before an acute admission and persisted for 10 days afterwards. Red alerts increased 1 day before admission and remained until 10 days after admission. Conclusion: A pre-hospital phase of Post-Hospital Syndrome may exist, with high levels of significant symptoms, poor health, low mood and pain before medical admission, as well as afterwards. This pre-hospital phase needs further investigation and may allow better admission planning or the use of alternative approaches.
Objective: To estimate the potential improvement in acute and rehabilitation hospital length of s... more Objective: To estimate the potential improvement in acute and rehabilitation hospital length of stay for rehabilitation patients from hypothetical scenarios that address barriers to patient flow. Design: Data about the duration of key processes for patients (n = 360) admitted to acute hospitals and subsequently transferred to inpatient rehabilitation in 2 wards in Melbourne, Australia were used to develop a computer simulation model. Subjects: Simulated patients. Methods: A computer model of length of stay was developed, validation checks performed and alternate care pathways simulated. Results: Almost all scenarios resulted in significant changes in the length of stay compared with baseline. The effect size for the changes was typically small to medium. The duration of the rehabilitation discharge barriers showed significant changes in all hypothetical scenarios. The effect size was smaller when changes were made to a single barrier, but larger when multiple barriers were changed simultaneously. Conclusion: Health system modelling can provide information regarding potential improvements in length of stay from addressing barriers to patient flow affecting rehabilitation patients. This can inform reforms to models of care and assist with cost benefit analyses.
Clinical handover is an essential process occurring at many levels of inpatient care. Multiple st... more Clinical handover is an essential process occurring at many levels of inpatient care. Multiple studies within a hospital setting have identified that a breakdown in the handover process can lead to poor patient outcomes and serious adverse events. The use of electronic handover tools is an intervention identified to decrease errors in clinical care arising from poor handover practice. An electronic handover tool was implemented in a general medical unit in a metropolitan tertiary hospital setting. The program was written by a Medical Professional who also used the tool. The program was evaluated with a pre-and post-intervention survey within the medical, allied health and nursing staff members of the multidisciplinary teams. The use of the Electronic Handover program resulted in improved satisfaction of the handover process within the medical, nursing and allied health professions. This trial demonstrates that an electronic handover program can be successfully integrated into normal medical work practice, resulting in positive outcomes for a multidisciplinary staff team. Further work is required to determine whether patient outcomes are improved as a result.
The antimicrobial susceptibilities of 100 clinical isolates ofPseudononas aeruginosa to gentamici... more The antimicrobial susceptibilities of 100 clinical isolates ofPseudononas aeruginosa to gentamicin, amikacin, tobramycin, ticarcillin, piperacillin, and ceftazidime were determined by using the Sceptor system (BBL Microbiology Systems, Cockeysville, Md.), and the results were compared with those obtained using the National Committee for Clinical Laboratory Standards reference agar dilution method. Excellent correlation was observed for the aminoglycosides, with >95% agreement within 1 doubling dilution of the reference agar dilution MIC, while ticarcillin and piperacillin showed lower percent agreement values of 91 and 88%,
Rationale, Aims, and ObjectivesHealthLinks: Chronic Care is a state‐wide public hospital initiati... more Rationale, Aims, and ObjectivesHealthLinks: Chronic Care is a state‐wide public hospital initiative designed to improve care for cohorts at‐risk of potentially preventable hospitalizations at no extra cost. MonashWatch (MW) is an hospital outreach service designed to optimize admissions in an at‐risk cohort. Telehealth operators make regular phone calls (≥weekly) using the Patient Journey Record System (PaJR). PaJR generates flags based on patient self‐report, alerting to a risk of admission or emergency department attendance. ‘Total flags’ of global health represent concerns about self‐reported general health, medication, and wellness. ‘Red flags’ represent significant disease/symptoms concerns, likely to lead to hospitalization.MethodsA time series analysis of PaJR phone calls to MW patients with ≥1 acute non‐surgical admissions in a 20‐day time window (10 days pre‐admission and 10 days post‐discharge) between 23 December 2016 and 11 October 2017. Pettitt's hypothesis‐testing ...
Background: MonashWatch is a telehealth public hospital outreach pilot service as a component of ... more Background: MonashWatch is a telehealth public hospital outreach pilot service as a component of the Government of Victoria's statewide redesign initiative called HealthLinks: Chronic Care. Rather than only paying for hospitalizations, projected funding is released earlier to hospitals to allow them to reduce hospitalization costs. MonashWatch introduced a web-based app, Patient Journey Record System, to assess the risk of the journeys of a cohort of patients identified as frequent admitters. Telecare guides call patients using the Patient Journey Record System to flag potential deterioration. Health coaches (nursing and allied health staff) triage risk and adapt care for individuals. Objective: The aim was a pragmatic controlled evaluation of the impact of MonashWatch on the primary outcome of bed days for acute nonsurgical admissions in the intention-to-treat group versus the usual care group. The secondary outcome was hospital admission rates. The net promoter score was used to gauge satisfaction. Methods: Patients were recruited into an intention-to-treat group, which included active telehealth and declined/lost/died groups, versus a systematically sampled (4:1) usual care group. A rolling sample of 250-300 active telehealth patients was maintained from December 23, 2016 to June 23, 2019. The outcome-mean bed days in intervention versus control-was adjusted using analysis of covariance for age, gender, admission type, and effective days active in MonashWatch. Time-series analysis tested for trends in change patterns. Results: MonashWatch recruited 1373 suitable patients who were allocated into the groups: usual care (n=293) and intention-to-treat (n=1080; active telehealth: 471/1080, 43.6%; declined: 485, 44.9%; lost to follow-up: 178 /1080, 10.7%; died: 8/1080, 0.7%). Admission frequency of intention-to-treat compared to that of the usual care group did not significantly improve (P=.05), with a small number of very frequent admitters in the intention-to-treat group. Age, MonashWatch effective days active, and treatment group independently predicted bed days. The analysis of covariance demonstrated a reduction in bed days of 1.14 (P<.001) in the intention-to-treat group compared with that in the usual care group, with 1236 bed days estimated savings. Both groups demonstrated regression-to-the-mean. The downward trend in improved bed days was significantly greater (P<.001) in the intention-to-treat group (Sen slope-406) than in the usual care group (Sen slope-104). The net promoter score was 95% in the active telehealth group compared with typical hospital scores of 77%. Conclusions: Clinically and statistically meaningful reductions in acute hospital bed days in the intention-to-treat group when compared to that of the usual care group were demonstrated (P<.001), although admission frequency was unchanged with more short stay admissions in the intention-to-treat group. Nonrandomized control selection was a limitation. Nonetheless, MonashWatch was successful in the context of the HealthLinks: Chronic Care capitation initiative and is expanding.
Modern healthcare has delivered achievements that no one could have anticipated prior to World Wa... more Modern healthcare has delivered achievements that no one could have anticipated prior to World War II, largely driven by science in both discovery and application mode. Why then do so many now feel that modern healthcare is failing to deliver on the unwritten promise that as each year unfolds greater gains will be delivered than in the year before? Design and systems thinking offers an opportunity for healthcare workers to co-design new ways of organising and delivering services. First, however, healthcare workers will need to learn new technical skills and gain a greater appreciation of the sociotechnical construction of heath service delivery as well as receive instruction in new methods so that these new ways of being and organising service delivery can be brought into effect. This will have profound implications for existing service delivery models and organisations. This chapter outlines and illustrates some approaches that can and are being taken to train and educate the healthcare workforce to design and bring into being the healthcare organisations and systems for the future. It is not clear which clinicians and students are best suited to learn and apply the methods and mindsets of design and systems thinking, nor which settings and contexts are best suited to the application of these methods. Research on the teaching and learning experience will guide further developments in the teaching of design and systems thinking for healthcare professionals.
Background: Standardised structure and content of interdisciplinary medical ward rounds can promo... more Background: Standardised structure and content of interdisciplinary medical ward rounds can promote patient safety and patient-centred teamwork. Aims: This study aimed to evaluate interdisciplinary ward rounds using a Structured Interdisciplinary Bedside Rounding (SIBR). Methods: Multi-method, repeat measures with a non-equivalent control group. Non-participant observations were, collected at one and six months, on an intervention ward that introduced SIBR and a control ward that continued traditional rounds. F ocus group and survey data were also collected on the intervention ward. Participants were clinicians (medicine, nursing and allied health) working in two general medicine wards at a tertiary hospital in Melbourne, Australia.
International Journal of Integrated Care, Aug 8, 2019
Suggestions for future research: Research into the improvement in the nexus of Big Data predictiv... more Suggestions for future research: Research into the improvement in the nexus of Big Data predictive analytics and anticipatory care in the quest to intervene in the emergent observable state of a person's health to improve health and better utilize health care resources.
Australia, like most other countries, has grown up with susceptibility testing in many forms, sub... more Australia, like most other countries, has grown up with susceptibility testing in many forms, subject to international forces and local whims. Consistent with its history, ELSEVIER
BACKGROUND Monash Watch (MW) aims to reduce avoidable hospitalizations in a cohort above a risk ‘... more BACKGROUND Monash Watch (MW) aims to reduce avoidable hospitalizations in a cohort above a risk ‘threshold’ identified by HealthLinks Chronic Care (HLCC) algorithms using personal, diagnostic, and service data, excluding surgical and psychiatric admissions. MW conducted regular patient monitoring through outbound phone calls using the Patient Journey Record System (PaJR). PaJR alerts are intended to act as a self-reported barometer of health perceptions with more alerts per call indicating greater risk of Potentially Preventable Hospitalizations (PPH) and Post Hospital Syndrome (PHS). Most knowledge of PPH and PHS occurs at a macro-level with little understanding of fine-grained dynamics. OBJECTIVE To describe patterns of self-reported concerns and self-rated health 10 days before and after acute hospital admission in the telehealth intervention cohort of MonashWatch in the context of addressing PPH and PHS. METHODS Participants: 173 who had an acute admission of the of the 232 HLCC cohort with predicted 3+ admissions/year, in MW service arm for &amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;40 days. Measures: Self-reported health and health care status in 764 MW phone call records which were classified into Total Alerts (all concerns - self-reported) and Red Alerts (concerns judged to be higher risk of adverse outcomes/admissions -acute medical and illness symptoms). Acute (non-surgical) admissions from Victorian Admitted Episode database. Analysis: Descriptive Timeseries homogeneity metrics using XLSTAT. RESULTS Self-reported problems (Total Alerts) statistically shifted to a higher level 3 days before an acute admission and stayed at a high level for the 10 days post discharge; reported acute medical and illness symptoms (Red Alerts) increased 1 day prior to admission and but remained at a higher level than before admission. Symptoms of concern did not change before admission or after discharge. Self-rated health and feeling depressed were reported to worsen 5 days post discharge. Patients reported more medication changes up to 2 days before acute admission. CONCLUSIONS These descriptive findings in a cohort of high risk individuals suggest a prehospital phase of what is termed PHS, which persisted on discharge and possibly worsened 5 days after discharge with worse self-rated health and depressive symptoms. Further research is needed. The role and place of community and hospital in such a cohort needs further investigation and research into PPH and PHS.
Hospital readmissions are the consequence of an individual unstable health journeys in the contex... more Hospital readmissions are the consequence of an individual unstable health journeys in the context of their local health services and community configurations. The Patient Journey Record System (PaJR) has developed a conversational approach with care guides and clinician coaches who support such health journeys irrespective of condition and location.
International Journal of Integrated Care, Feb 26, 2021
Post-hospital syndrome (PHS) is a state of increased vulnerability to ill-health in the 10 days p... more Post-hospital syndrome (PHS) is a state of increased vulnerability to ill-health in the 10 days post discharge, but what health states lead to admission? This study investigates health profiles/symptoms 10 days before and after acute medical admissions in Monash Watch (MW)-a hospital telehealth pilot to optimize avoidable hospitalizations in those with predicted risk of 3+ hospitalizations using hospital algorithms. Methods: Telecare guides conduct regular patient outbound phone calls. More alerts per call indicate greater risk. Total alerts represent general health, psychosocial and care issues. Red alerts represent medical symptoms and illness. Design: A cohort study of MW subgroup of 103 admitted patients (total sample 233). Data: Self-reported health profiles and alerts in 764 MW phone call records and acute (nonsurgical) admissions data over a 6 month period Analytics: Descriptive time series using homogeneity metrics with XLSTAT. Results: Fair to poor self-rated health was reported 10 days before until 5 days after admission. Moderate to severe pain and feeling depressed was reported from 10 days before to 10 days after admissions. Total alerts statistically increased 3 days before an acute admission and persisted for 10 days afterwards. Red alerts increased 1 day before admission and remained until 10 days after admission. Conclusion: A pre-hospital phase of Post-Hospital Syndrome may exist, with high levels of significant symptoms, poor health, low mood and pain before medical admission, as well as afterwards. This pre-hospital phase needs further investigation and may allow better admission planning or the use of alternative approaches.
Objective: To estimate the potential improvement in acute and rehabilitation hospital length of s... more Objective: To estimate the potential improvement in acute and rehabilitation hospital length of stay for rehabilitation patients from hypothetical scenarios that address barriers to patient flow. Design: Data about the duration of key processes for patients (n = 360) admitted to acute hospitals and subsequently transferred to inpatient rehabilitation in 2 wards in Melbourne, Australia were used to develop a computer simulation model. Subjects: Simulated patients. Methods: A computer model of length of stay was developed, validation checks performed and alternate care pathways simulated. Results: Almost all scenarios resulted in significant changes in the length of stay compared with baseline. The effect size for the changes was typically small to medium. The duration of the rehabilitation discharge barriers showed significant changes in all hypothetical scenarios. The effect size was smaller when changes were made to a single barrier, but larger when multiple barriers were changed simultaneously. Conclusion: Health system modelling can provide information regarding potential improvements in length of stay from addressing barriers to patient flow affecting rehabilitation patients. This can inform reforms to models of care and assist with cost benefit analyses.
Clinical handover is an essential process occurring at many levels of inpatient care. Multiple st... more Clinical handover is an essential process occurring at many levels of inpatient care. Multiple studies within a hospital setting have identified that a breakdown in the handover process can lead to poor patient outcomes and serious adverse events. The use of electronic handover tools is an intervention identified to decrease errors in clinical care arising from poor handover practice. An electronic handover tool was implemented in a general medical unit in a metropolitan tertiary hospital setting. The program was written by a Medical Professional who also used the tool. The program was evaluated with a pre-and post-intervention survey within the medical, allied health and nursing staff members of the multidisciplinary teams. The use of the Electronic Handover program resulted in improved satisfaction of the handover process within the medical, nursing and allied health professions. This trial demonstrates that an electronic handover program can be successfully integrated into normal medical work practice, resulting in positive outcomes for a multidisciplinary staff team. Further work is required to determine whether patient outcomes are improved as a result.
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Papers by Keith Stockman