A national postal survey was sent to all speech and language therapy managers/directors in England and Wales (n =206), to identify individuals aged 8-18 years with a cleft palate, who have persisting communication difficul-ties. Twelve of the 303 young people identified in the survey were studied further through a residential intervention programme (July 1999). The findings have far-reaching implications for all involved in the management of these children/adolescents’ psychosocial welfare, especially the Cleft Palate Team and those responsible for their education. [The term ‘cleft palate’ incorporates those with cleft lip and palate and non-cleft velopharyngeal incompetence (VPI).]

Speech and language deficits frequently implicate accompanying psychosocial problems (such as low self-esteem). An alternative management approach is described which adopts a holistic paradigm and provides a unique opportunity for intensive work on communication within a supportive environment. The residential programme for 8-14 year olds with persistent communication difficulties incorporated cognitive, emotional and psychosocial dimensions of communication, co-ordinated with work on speech features. Although the programmes were developed for children with cleft palate, they have potential for benefiting a wide range of communication impairments of different aetiologies. A forthcoming manual with resource material developed by the research team will be used in studies across these groups.

Objective: To compare empiric and protocol-based therapies of neuromuscular blockade in terms of cost and control of paralysis.Methods: Data were prospectively collected for nine months before and five months after a protocol was implemented in the 24-bed medical/surgical/neurologic intensive care unit as a physician-initiated, doublesided medication order form. Pancuronium was the preferred agent and vecuronium was an alternative for patients with renal dysfunction, hepatic dysfunction, or hemodynamic instability.Results: Twenty-nine empiric-therapy patients and 17 protocol-based therapy patients were comparatively evaluated. Length of stay in the intensive care unit and duration of neuromuscular blockade were similar between groups. Protocol adherence rate was 76.5%. Protocol-based therapy increased the hourly dose of pancuronium (0.29 ± 0.37 mg vs. 0.02 ± 0.10 mg; p < 0.005) and reduced the mean hourly cost of neuromuscular blockade compared with empiric therapy ($5.11 ± 4.76 Canadian [CDN] vs. $9.03 ± 7.03 CDN; p < 0.05). Vecuronium use did not change, but rocuronium and atracurium were not given after protocol implementation. The proportion of recorded train-of-four measurements representing adequate neuromuscular blockade increased (52.3% vs. 32.7%; p < 0.05) with protocol-based therapy.Conclusions: Compliance with a neuromuscular blocking protocol reduces drug costs and improves control of neuromuscular blockade.

Purpose: As the medical and surgical complexity of pediatric heart transplants (PHTx) continues to increase, individualized treatment plans are increasingly important. Given the uncertain timing of heart transplant surgeries and the involvement of several different providers, multi-disciplinary communication at the time of transplant surgery is critical to safe execution of the transplant plan. Methods: A pre-transplant flight plan (FP) and huddle (PTH) developed by Stanford University was implemented as a quality improvement project at Children's Medical Center of Dallas. The FP is a detailed pre-, peri-, and postoperative management plan developed at listing by all involved stakeholders, and updated monthly until PHTx.(Figure 1) After organ acceptance, the FP is reviewed by the on-call multidisciplinary team at a PTH. Project impact is evaluated with multidisciplinary pre-and post-implementation surveys. Preimplantation surveys included all Heart Center professionals. Professionals who participated in a huddle participated in the post-implementation survey.The key outcome metric is 30-day post-transplant survival. Results: 7 transplants included a FP/PTH, with a 30-day survival of 100%. A pre-implementation survey (n=169) indicated the minority of respondents (24%), agreed or strongly agreed that peri-transplant communication was good. Post-implementation survey (n=16) demonstrated that 87.5% agreed or strongly agreed that the FP/PTH improved multi-disciplinary peri-transplant communication, and 87.5% agreed or strongly agreed peritransplant multi-disciplinary communication was good. Conclusion: A transplant FP/PTH improves multi-disciplinary communication at the time of PHTx. Key lessons include ability to conduct PTH through virtual platform, standard data definitions, and EMR optimization for flight plan. Long-term data collection will indicate whether the flight plan improves delivery of care and/or patient outcomes.