The team approach

Teamwork is emerging like a model of prevailing reference in many working fields: the interaction and, above all, integration between several persons can be an instrument to empower the individual skills, allowing to reach different and higher levels of creativity and efficiency than the sum of the single members' capacities. However, the capacity of interaction, tolerance, and focusing on the problem is required to the members who also need training for this way of working. After a brief historical summary of some 'creative groups' experiences in the fields of literature, science and arts, a vast review of theoretical model references is presented. Starting from specific North-American guidelines, a hypothesis of nutritional teamwork is introduced. This hypothesis aims at optimizing therapeutic interventions, at the critical review of the provided services and at a greater care for the cost-benefit ratio.     

Critical care bug team: a multidisciplinary team approach to reducing ventilator-associated pneumonia

BACKGROUND: Ventilator-associated pneumonia rates in the medical-surgical intensive care unit first exceeded the 90th percentile in September 1997 and were significantly (P <.05) higher than National Nosocomial Infections Surveillance System pooled mean data. In January 1998, a multidisciplinary "Critical Care Bug Team" was developed by the Infection Control Committee to review 1997 National Nosocomial Infections Surveillance System data for four adult intensive care units in a 583-bed tertiary care hospital. METHODS: Membership included clinical nurse specialists, a dietitian, a pharmacist, a respiratory therapist, an infection control professional, a research specialist, and a physician adviser. Having the team report directly to the hospital's Infection Control and Adult Critical Care Committees maximized support for recommendations and provided a direct link from patient care to hospital administration. By identifying issues, evaluating patient care processes, performing literature searches, and monitoring compliance, the team implemented numerous interventions, including policy and procedure changes, purchasing of equipment, and implementation of various education tools. RESULTS: Each member of the Critical Care Bug Team contributed to a synergized effort that may have produced the desired outcome of decreasing ventilator-associated pneumonia rates. Except for August 1998, ventilator-associated pneumonia rates have been below the 75th percentile since May 1998. CONCLUSION: This study illustrates the effectiveness of a multidisciplinary team approach devised to reduce and stabilize ventilator-associated pneumonia rates in a medical-surgical intensive care unit.     

In support of an early polypharmacy approach to the treatment of type 2 diabetes

Type 2 diabetes (T2DM) is a multifaceted disease, characterized by hyperglycaemia, resulting from a combination of insulin resistance, impaired incretin action and β-cell dysfunction leading to relative insulin deficiency. Although traditional anti-diabetes agents improve hyperglycaemia, they do so at a cost, which may entail hypoglycemia and increased body weight; exacerbating dyslipidemia, hypertension and components of insulin resistance and metabolic syndrome associated with T2DM-potentially increasing cardiovascular risk. At diagnosis, many patients with T2DM are treated with medical nutritional therapy (MNT) and exercise, then single or multiple oral anti-diabetes agents until treatment failure, when insulin is used. This strategy has been challenged by recommendations for polypharmacy approaches to the treatment of T2DM, as current strategies are unable to improve multiple aspects of the disease, nor are they likely to address underlying pathophysiology. Although the 2009 American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) treatment algorithm recommends a stepwise approach with MNT and metformin, later adding oral agents, incretin-based therapies or insulin, some experts have recommended a more aggressive approach. In his 2008 ADA Banting Lecture, Dr. Ralph DeFronzo recommended early treatment with metformin, TZD and exenatide at initiation of therapy. The authors' of this article recommend an aggressive early polypharmacy approach addressing underlying pathophysiology, including the incretin defect-with MNT and exercise, metformin and an incretin-based therapy and/or basal insulin if glycemic goal is not achieved within 3 months. This approach attempts to modify the disease, aiming for tight glycemic control, weight loss, reduced hypoglycemia, improvements to hypertension, dyslipidemia and insulin resistance-and improved cardiovascular outcomes.     

The psychosocial treatment of recurrent diabetic ketoacidosis: an interdisciplinary team approach

The professional expertise of the diabetes mental health professional is integral to the interdisciplinary team approach to recurrent diabetic ketoacidosis (DKA). A case report provides the context to illustrate the interconnection of concurrent strategies of diabetes management, teaching, and counseling. Specific methods include a practical approach to manipulative behavior in blood glucose monitoring, supervision of insulin administration, education, and intensive psychotherapy. In this case study, the adolescent's removal from her home environment, along with medical supervision and extensive psychosocial support, was instrumental in reversing the pattern of self-destructiveness. Recurrent DKA is a very specific problem for which the mental health professional can play an effective treatment role.     

The team approach to pregnancy and congenital heart disease

The successful pediatric management of congenital heart disease has resulted in increasing numbers of these patients in the reproductive age group and increasing clinical challenges for their physicians. These challenges can be met successfully, with improved results for mother and child, through a concerted comprehensive team approach that relies on a thorough understanding of the patient's underlying cardiac pathology and its anticipated interaction with the pregnancy, and ongoing close evaluation and communication with a team of trained and experienced specialist, including (but not limited to) cardiologist, obstetricians, anesthetists, pediatricians, clinical nurse specialists, and clinical geneticists. Such teams are not always available locally and it will be necessary to refer medium- and high-risk patients to a specialized tertiary care center.