Outcomes of re-referrals of patients with alcohol-associated liver disease, who were previously declined for liver transplantation.

Since 2018, our program has utilized specific psychosocial criteria and a multidisciplinary approach to assess patients for liver transplant due to alcohol-associated liver disease (ALD), rather than the 6-month abstinence rule alone. If declined based on these criteria, specific recommendations are provided to patients and their providers regarding goals for re-referral to increase the potential for future transplant candidacy. Recommendations include engagement in treatment for alcohol use disorder, serial negative biomarker testing, and maintenance of abstinence from alcohol. In our current study, we evaluate the outcomes of patients with ALD, who were initially declined upon assessment and re-referred to our program. This is a retrospective cohort study that includes 98 patients with ALD, who were previously declined for liver transplantation and were subsequently re-referred for liver transplant assessment between May 1, 2018, and December 31, 2021. We assess the outcomes of patients who were re-referred including acceptance for transplantation following a second assessment. Of the 98 patients who were re-referred, 46 (46.9%) fulfilled the recommendations made and proceeded to further medical evaluation. Nine were eventually transplanted; others are listed and are waiting for transplant. The presence of a partner was independently associated with a higher rate of acceptance (OR 0.16, 95% CI: 0.03-0.97, p = 0.05). Most of the patients who did not proceed further (n = 52) were declined again due to ALD contraindications (n = 33, 63.4%), including ongoing drinking and lack of engagement in recommended addiction treatment. Others had medical contraindications (11.2%), clinically improved (6.1%), had adherence issues (5.1%), or lack of adequate support (2%). Patients with ALD previously declined for a liver transplant can be re-referred and successfully accepted for transplantation by fulfilling the recommendations made by the multidisciplinary team. Important factors including ongoing abstinence, engagement in addiction treatment, and social support are key for successful acceptance.

Anomalies in the review process and interpretation of the evidence in the NICE guideline for chronic fatigue syndrome and myalgic encephalomyelitis.

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a disabling long-term condition of unknown cause. The National Institute for Health and Care Excellence (NICE) published a guideline in 2021 that highlighted the seriousness of the condition, but also recommended that graded exercise therapy (GET) should not be used and cognitive-behavioural therapy should only be used to manage symptoms and reduce distress, not to aid recovery. This U-turn in recommendations from the previous 2007 guideline is controversial.We suggest that the controversy stems from anomalies in both processing and interpretation of the evidence by the NICE committee. The committee: (1) created a new definition of CFS/ME, which 'downgraded' the certainty of trial evidence; (2) omitted data from standard trial end points used to assess efficacy; (3) discounted trial data when assessing treatment harm in favour of lower quality surveys and qualitative studies; (4) minimised the importance of fatigue as an outcome; (5) did not use accepted practices to synthesise trial evidence adequately using GRADE (Grading of Recommendations, Assessment, Development and Evaluations trial evidence); (6) interpreted GET as mandating fixed increments of change when trials defined it as collaborative, negotiated and symptom dependent; (7) deviated from NICE recommendations of rehabilitation for related conditions, such as chronic primary pain and (8) recommended an energy management approach in the absence of supportive research evidence.We conclude that the dissonance between this and the previous guideline was the result of deviating from usual scientific standards of the NICE process. The consequences of this are that patients may be denied helpful treatments and therefore risk persistent ill health and disability.

"Don't Just Study our Distress, Do Something": Implementing and Evaluating a Modified Stepped-Care Model for Health Care Worker Mental Health During the COVID-19 Pandemic.

OBJECTIVE: Throughout the COVID-19 pandemic, there have been concerns about the mental health of health care workers (HCW). Although numerous studies have investigated the level of distress among HCW, few studies have explored programs to improve their mental well-being. In this paper, we describe the implementation and evaluation of a program to support the mental health of HCW at University Health Network (UHN), Canada's largest healthcare network. METHODS: Using a quality improvement approach, we conducted a needs assessment and then created and evaluated a modified stepped-care model to address HCW mental health during the pandemic. This included: online resources focused on psychoeducation and self-management, access to online support and psychotherapeutic groups, and self-referral for individual care from a psychologist or psychiatrist. We used ongoing mixed-methods evaluation, combining quantitative and qualitative analysis, to improve program quality. RESULTS: The program is ongoing, running continuously throughout the pandemic. We present data up to November 30, 2021. There were over 12,000 hits to the UHN's COVID mental health intranet web page, which included self-management resources and information on group support. One hundred and sixty-six people self-referred for individual psychological or psychiatric care. The mean wait time from referral to initial appointment was 5.4 days, with an average of seven appointments for each service user. The majority had moderate to severe symptoms of depression and anxiety at referral, with over 20% expressing thoughts of self-harm or suicide. Post-care user feedback, collected through self-report surveys and semistructured interviews, indicated that the program is effective and valued. CONCLUSIONS: Development of a high-quality internal mental health support for HCW program is feasible, effective, and highly valued. By using early and frequent feedback from multiple perspectives and stakeholders to address demand and implement changes responsively, the program was adjusted to meet HCW mental health needs as the pandemic evolved.

Results of Early Transplantation for Alcohol-Related Cirrhosis: Integrated Addiction Treatment With Low Rate of Relapse.

BACKGROUND & AIMS: In 2018, our team initiated a prospective pilot program to challenge the paradigm of the "6-month rule" of abstinence for patients with alcohol-related liver disease (ALD) requiring transplant. Our pilot involved an in-depth examination of patients' alcohol use, social support, and psychiatric comorbidity, as well as the provision of pre- and post-transplantation addiction treatment. METHODS: Patients with ALD were assessed for inclusion in the pilot by a multidisciplinary team. Relapse prevention therapy was provided directly to all patients deemed to meet the program's inclusion criteria. Random biomarker testing for alcohol was used pre and post transplantation. RESULTS: We received 703 referrals from May 1, 2018 to October 31, 2020. After fulfilling the program's criteria, 101 patients (14%) were listed for transplantation and 44 (6.2%) received transplants. There were no significant differences in survival rates between those receiving transplants through the pilot program compared with a control group with more than 6 months of abstinence (P = .07). Three patients returned to alcohol use during an average post-transplantation follow-up period of 339 days. In a multivariate analysis, younger age and lower Model for End-Stage Liver Disease scores at listing were associated with an increased likelihood of a return to alcohol use (P < .05); length of abstinence was not a predictor. CONCLUSIONS: Our prospective program provided direct monitoring and relapse prevention treatment for patients with ALD and with less than 6 months of abstinence and resulted in a reduction of post-transplantation return to drinking. This pilot study provides a framework for the future of more equitable transplant care.

Anonymity: What does it mean and why is it important to anonymous living liver donors?

Anonymous living organ donation has recently become more common in select transplantation programs, with donors voluntarily offering a kidney or a lobe of their liver to those in need. These anonymous donations may be directed to a specific recipient or nondirected, and anonymity may be one way or reciprocal. Given their unique situation, we interviewed a cohort of anonymous living liver donors and explored their opinions surrounding anonymity and its implications in living liver donation. A total of 26 anonymous donors completed a semistructured qualitative interview consisting of questions regarding their experiences as a living liver donor. The interviews were audio-recorded, transcribed, and analyzed for common themes, specifically those pertaining to the donor's perceptions and experiences with anonymity. Five main themes related to anonymity were identified: (1) the moral importance of an unencumbered gift, (2) wanting internal satisfaction rather than seeking external accolades, (3) anonymity as a protection against potential negative outcomes in the recipient, (4) feelings of ambivalence toward meeting the recipient, and (5) concerns about negative perceptions among their own friends and family. These insights into the range of donors' attitudes toward anonymity will help improve awareness and provide the best possible mental and physical care for the anonymous donor.

Anonymous living liver donor perspectives on the role of family in their donation experience.

Anonymous living organ donation is an understudied but rapidly expanding sector in organ transplantation, in which donors choose to donate anonymously to a recipient in need. The family members and close support network of living donors often play a crucial role in the donation process, and their influence likely has a large impact on the decision to donate as well as the donor's physical and psychosocial state. However, there is limited data examining the impact donor families have on the anonymous donor, and in turn, the impact donation has on donors' families. To assess this, we analyzed a semi-structured qualitative interview on living donor experiences with 26 anonymous living liver donors for common themes concerning donor families. Responses surrounding donor families were grouped into three major categories: (1) family reactions to donation, ranging from (a) pride/support, (b) fear/worry, and (c) jealousy/anger; (2) the impact of donation on donor-family relationships, including (a) positive impacts, (b) negative impacts, (c) a positive ripple effect; (3) gaps in institutional support for donor families. This study provides unique information on anonymous living liver donor perceptions related to their families and will help improve existing programs to accommodate donor family needs and cater to donor relationships.

Future public health emergencies and disasters: sustainability and insights into support programs for healthcare providers.

BACKGROUND: The mental health of healthcare workers (HCWs) has been at the forefront throughout the COVID-19 pandemic. While workplace-based support programs have been developed in hospitals globally, few systematically collected data. While critical to their success, information on these programs and the experience of mental healthcare providers (MHP) who support colleagues is limited. The objective of this study was to explore the experiences of MHP caring for HCW colleagues within a novel workplace-based mental health support program during the COVID-19 pandemic, to provide insights on facilitators, areas for improvement and barriers to program sustainability. METHODS: This qualitative study used semi-structured interviews conducted by videoconference between September 2020 to October 2021. UHN CARES (University Health Network Coping and Resilience for Employees and Staff) Program was developed during the first wave of the COVID-19 pandemic in March 2020. It supports over 21,000 staff members within the UHN, Canada's largest academic health research institution, in Toronto, Canada. Purposive sampling was used to select 10 of the 22 MHP in the UHN CARES Program (n = 10). Using a critical realism framework, key components required to sustain a successful workplace-based mental health support program for HCWs and balance the needs of MHP were determined. RESULTS: Six psychiatrists and four psychologists (n = 10) with varying roles at UHN participated in 17 interviews, including seven repeat interviews exploring changes over time within the pandemic and program. Components which facilitated the success of the program included flexibility in scheduling, confidential health record storage, comprehensive administrative support, availability of resources and adaptive quality improvement approach. Recommendations for improvement included opportunities for peer supervision, triaging of cases, and managing HCW expectations. MHP found caring for HCWs to be meaningful and they utilized existing clinical skills during sessions. Challenges included working in a virtual setting, navigating boundaries when caring for colleagues, and managing the range of service users and their needs. CONCLUSIONS: These findings suggest how support programs can be structured for HCWs, how to provide support, and how to sustain this support, allowing health systems to balance the needs of HCWs and MHPs in preparation for future public health emergencies.

Lung transplant recipient attitudes and beliefs on accepting an organ that is positive for hepatitis C virus.

INTRODUCTION: Little is known about patient perceptions regarding HCV+ organ use in non-HCV-infected recipients. This study examined factors influencing the decision to accept HCV+ organs and the resulting impacts. METHODS: Adult lung transplant (LT) patients or candidates who had consented to receive an HCV+ organ completed a survey including multiple choice, a five-point Likert scale, and free-text answers. A total of 67 LT recipients or candidates who had consented to receive HCV+ organs were enrolled, of which 21/67 (31%) received HCV+ lungs, 39 (58%) HCV- lungs, and seven (10%) were still waiting. RESULTS: Pre-transplant, 50/67 (75%) patients felt it was either "completely safe" or "very safe" to accept an HCV+ organ. Although 22/67 (33%) said they never or rarely took risks, they still made the decision to accept an HCV+ organ. Common reported reasons were desperation, perception of having "no choice," and increasing symptom severity. In the subset of patients that were transplanted with an HCV+ organ (n = 21), only 12.5% reported second thoughts about accepting. Post-transplant, the majority (87.5%) never felt any anxiety about HCV and most (83%) reported no impact from HCV. Perception of treatment tolerability and ease was highly favorable. CONCLUSION: Use of HCV+ organs demonstrated minimal detrimental perceived impacts on lung transplant patients. Patients generally found the experience to be very positive.

The psychological burden of waiting for procedures and patient-centred strategies that could support the mental health of wait-listed patients and caregivers during the COVID-19 pandemic: A scoping review.

BACKGROUND: Waiting for procedures delayed by COVID-19 may cause anxiety and related adverse consequences. OBJECTIVE: To synthesize research on the mental health impact of waiting and patient-centred mitigation strategies that could be applied in the COVID-19 context. METHODS: Using a scoping review approach, we searched 9 databases for studies on waiting lists and mental health and reported study characteristics, impacts and intervention attributes and outcomes. RESULTS: We included 51 studies that focussed on organ transplant (60.8%), surgery (21.6%) or cancer management (13.7%). Most patients and caregivers reported anxiety, depression and poor quality of life, which deteriorated with increasing wait time. The impact of waiting on mental health was greater among women and new immigrants, and those of younger age, lower socio-economic status, or with less-positive coping ability. Six studies evaluated educational strategies to develop coping skills: 2 reduced depression (2 did not), 1 reduced anxiety (2 did not) and 2 improved quality of life (2 did not). In contrast, patients desired acknowledgement of concerns, peer support, and periodic communication about wait-list position, prioritization criteria and anticipated procedure date. CONCLUSIONS: Findings revealed patient-centred strategies to alleviate the mental health impact of waiting for procedures. Ongoing research should explore how to optimize the impact of those strategies for diverse patients and caregivers, particularly in the COVID-19 context. PATIENT OR PUBLIC CONTRIBUTION: Six patients and four caregivers waiting for COVID-19-delayed procedures helped to establish eligibility criteria, plan data extraction and review a draft and final report.

Donor outcomes in anonymous live liver donation.

BACKGROUND & AIMS: Death rates on liver transplant waiting lists range from 5%-25%. Herein, we report a unique experience with 50 anonymous individuals who volunteered to address this gap by offering to donate part of their liver to a recipient with whom they had no biological connection or prior relationship, so called anonymous live liver donation (A-LLD). METHODS: Candidates were screened to confirm excellent physical, mental, social, and financial health. Demographics and surgical outcomes were analyzed. Qualitative interviews after donation examined motivation and experiences. Validated self-reported questionnaires assessed personality traits and psychological impact. RESULTS: A total of 50 A-LLD liver transplants were performed between 2005 and 2017. Most donors had a university education, a middle-class income, and a history of prior altruism. Half were women. Median age was 38.5 years (range 20-59). Thirty-three (70%) learned about this opportunity through public or social media. Saving a life, helping others, generativity, and reciprocity for past generosity were motivators. Social, financial, healthcare, and legal support in Canada were identified as facilitators. A-LLD identified most with the personality traits of agreeableness and conscientiousness. The median hospital stay was 6 days. One donor experienced a Dindo-Clavien Grade 3 complication that completely resolved. One-year recipient survival was 91% in 22 adults and 97% in 28 children. No A-LLD reported regretting their decision. CONCLUSIONS: This is the first and only report of the characteristics, motivations and facilitators of A-LLD in a large cohort. With rigorous protocols, outcomes are excellent. A-LLD has significant potential to reduce the gap between transplant organ demand and availability. LAY SUMMARY: We report a unique experience with 50 living donors who volunteered to donate to a recipient with whom they had no biological connection or prior relationship (anonymous living donors). This report is the first to discuss motivations, strategies and facilitators that may mitigate physical, social and ethical risk factors in this patient population. With rigorous protocols, anonymous liver donation and recipient outcomes are excellent; with appropriate clinical expertise and system facilitators in place, our experience suggests that other centers may consider the procedure for its significant potential to reduce the gap between transplant organ demand and availability.

One-Year Outcomes in Caregivers of Critically Ill Patients.

BACKGROUND: Few resources are available to support caregivers of patients who have survived critical illness; consequently, the caregivers' own health may suffer. We studied caregiver and patient characteristics to determine which characteristics were associated with caregivers' health outcomes during the first year after patient discharge from an intensive care unit (ICU). METHODS: We prospectively enrolled 280 caregivers of patients who had received 7 or more days of mechanical ventilation in an ICU. Using hospital data and self-administered questionnaires, we collected information on caregiver and patient characteristics, including caregiver depressive symptoms, psychological well-being, health-related quality of life, sense of control over life, and effect of providing care on other activities. Assessments occurred 7 days and 3, 6, and 12 months after ICU discharge. RESULTS: The caregivers' mean age was 53 years, 70% were women, and 61% were caring for a spouse. A large percentage of caregivers (67% initially and 43% at 1 year) reported high levels of depressive symptoms. Depressive symptoms decreased at least partially with time in 84% of the caregivers but did not in 16%. Variables that were significantly associated with worse mental health outcomes in caregivers were younger age, greater effect of patient care on other activities, less social support, less sense of control over life, and less personal growth. No patient variables were consistently associated with caregiver outcomes over time. CONCLUSIONS: In this study, most caregivers of critically ill patients reported high levels of depressive symptoms, which commonly persisted up to 1 year and did not decrease in some caregivers. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov number, NCT00896220.).

The 2018 ISHLT/APM/AST/ICCAC/STSW Recommendations for the Psychosocial Evaluation of Adult Cardiothoracic Transplant Candidates and Candidates for Long-term Mechanical Circulatory Support.

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

Messy entanglements: research assemblages in heart transplantation discourses and practices.

The paper engages with a variety of data around a supposedly single biomedical event, that of heart transplantation. In conventional discourse, organ transplantation constitutes an unproblematised form of spare part surgery in which failing biological components are replaced by more efficient and enduring ones, but once that simple picture is complicated by employing a radically interdisciplinary approach, any biomedical certainty is profoundly disrupted. Our aim, as a cross-sectorial partnership, has been to explore the complexities of heart transplantation by explicitly entangling research from the arts, biosciences and humanities without privileging any one discourse. It has been no easy enterprise yet it has been highly productive of new insights. We draw on our own ongoing funded research with both heart donor families and recipients to explore our different perceptions of what constitutes data and to demonstrate how the dynamic entangling of multiple data produces a constitutive assemblage of elements in which no one can claim priority. Our claim is that the use of such research assemblages and the collaborations that we bring to our project breaks through disciplinary silos to enable a fuller comprehension of the significance and experience of heart transplantation in both theory and practice.

The RECOVER Program: Disability Risk Groups and 1-Year Outcome after 7 or More Days of Mechanical Ventilation.

RATIONALE: Disability risk groups and 1-year outcome after greater than or equal to 7 days of mechanical ventilation (MV) in medical/surgical intensive care unit (ICU) patients are unknown and may inform education, prognostication, rehabilitation, and study design. OBJECTIVES: To stratify patients for post-ICU disability and recovery to 1 year after critical illness. METHODS: We evaluated a multicenter cohort of 391 medical/surgical ICU patients who received greater than or equal to 1 week of MV at 7 days and 3, 6, and 12 months after ICU discharge. Disability risk groups were identified using recursive partitioning modeling. MEASUREMENTS AND MAIN RESULTS: The 7-day post-ICU Functional Independence Measure (FIM) determined the recovery trajectory to 1-year after ICU discharge and was an independent risk factor for 1-year mortality. The 7-day post-ICU FIM was predicted by age and ICU length of stay. By 2 weeks of MV, ICU patients could be stratified into four disability groups characterized by increasing risk for post ICU disability, ICU and post-ICU healthcare use, and disposition. Patients less than 42 years with ICU length of stay less than 2 weeks had the best function and fewest deaths at 1 year compared with patients greater than 66 years with ICU length of stay greater than 2 weeks who sustained the worst disability and 40% 1-year mortality. Depressive symptoms (17%) and post-traumatic stress disorder (18%) persisted at 1 year. CONCLUSIONS: ICU survivors of greater than or equal to 1 week of MV may be stratified into four disability groups based on age and ICU length of stay. These groups determine 1-year recovery and healthcare use and are independent of admitting diagnosis and illness severity. Clinical trial registered with www.clinicaltrials.gov (NCT 00896220).

The Transplant Palliative Care Clinic: An early palliative care model for patients in a transplant program.

Although patients within a transplant program are awaiting or have received disease modifying or curative treatment, they are also facing advanced illness and the possibility of death. The involvement of specialized palliative care services for these patients may improve symptom management and facilitate advance care planning. However, patients in organ transplantation programs have difficulty accessing palliative care resources and often do so only sporadically in the inpatient setting. Currently, there is little access to ambulatory palliative care for these patients and there have been no descriptions of programs delivering such care in the medical literature. We outline the development and structure of a Transplant Palliative Care Clinic within the University Health Network's Multi-Organ Transplant Program, in Toronto, Canada. This information may be helpful for others aiming to provide early, integrated palliative care to patients awaiting and receiving organ transplantation.

Time to Consultation-Liaison Psychiatry Service Referral as a Predictor of Length of Stay.

OBJECTIVES: The aim of this study was to determine the relationship between the time to referral (TTR) to psychiatric consultation and the length of stay (LOS) after adjusting for medical comorbity. METHODS: Using a naturalistic study design, we collected and analyzed inpatient consultation-liaison psychiatry service data over a 12-month period from 2 Canadian hospital sites. Data collected included demographic characteristics, referral characteristics, Charlson Comorbidity Index to measure medical comorbidity severity, psychiatric diagnoses, type of psychiatric intervention, and time variables, namely TTR and LOS. We modeled the relationship LOS and TTR after adjusting for Charlson Index using a 3-component finite mixture of exponential regression models. RESULTS: A total of 814 patients were included. The median LOS was 12 days (interquartile range : 4-28 days). Median TTR was 3 days (interquartile range: 1,9), and median Charlson Index was 5 (interquartile range 3,6). Bivariate analysis indicated a strong positive correlation among LOS and TTR (Spearman correlation: 0.77, p < 0.0001) and Charlson Index(Spearman correlation: 0.34, p < 0.0001), respectively. After controlling for Charlson Index, we observe that TTR was significantly associated with LOS in each of the 3 components of the mixture of exponential regression models. Persons with longer TTR have longer expected LOS. Graphical summaries suggest that the mixture of exponential regression model provides a good fit to these LOS response data. CONCLUSIONS: Patients with longer TTR had significantly longer LOS. The association between TTR and LOS holds after controlling for severity of medical comorbidity. Our results support the role of integrated and proactive consultation-liaison psychiatry programs aimed at reducing TTR to improve LOS outcomes.

Perceived Stigma among Recipients of Mental Health Care in the General Canadian Population.

OBJECTIVES: The Mental Health Experiences Scale is a measure of perceived stigma, the perception of negative attitudes and behaviours by people with mental disorders. A recent Canadian survey (Canadian Community Health Survey-Mental Health) included this scale, providing an opportunity to describe perceived stigma in relation to diagnosis for the first time in the Canadian general population. METHODS: The survey interview began with an assessment of whether respondents had utilised services for an "emotional or mental health problem" in the preceding 12 months. The subset reporting service utilisation were asked whether others "held negative opinions" about them or "treated them unfairly" for reasons related to their mental health. The analysis reported here used frequencies, means, cross-tabulation, and logistic regression, all incorporating recommended replicate sampling weights and bootstrap variance estimation procedures. RESULTS: Stigma was perceived by 24.4% of respondents accessing mental health services. The frequency was higher among younger respondents (<55 years), those who were not working, those reporting only fair or poor mental health, and the subset who reported having received a diagnosis of a mental disorder. Sex and education level were not associated with perceived stigma. People with schizophrenia reported stigmatization only slightly more frequently than those with mood and anxiety disorders. CONCLUSIONS: Stigmatization is a common, but not universal, experience among Canadians using services for mental health reasons. Stigmatization was a problem for a sizeable minority of respondents with mood, anxiety, and substance use disorders as well as bipolar and psychotic disorders.

Determining the need for team-based training in delirium management: A needs assessment of surgical healthcare professionals.

The high incidence of delirium in surgical units is a serious quality concern, given its impact on morbidity and mortality. While successful delirium management depends upon interdisciplinary care, training needs for surgical teams have not been studied. A needs assessment of surgical units was conducted to determine perceived comfort in managing delirium, and interprofessional training needs for team-based care. We administered a survey to 106 General Surgery healthcare professionals (69% response rate) with a focus on attitudes towards delirium and team management. Although most respondents identified delirium as important to patient outcomes, only 61% of healthcare professionals indicated that a team-based approach was always observed in practice. Less than half had a clear understanding of their role in delirium care, while just over half observed team communication of delirium care plans during handover. This is the first observation of clear gaps in perceived team performance in a General Surgery setting.

A framework for understanding international medical graduate challenges during transition into fellowship programs.

BACKGROUND: Previous studies have highlighted unique needs of international medical graduates (IMG) during their transition into medical training programs; however, limited data exist on IMG needs specific to fellowship training. PURPOSES: We conducted the following mixed-method study to determine IMG fellow training needs during the transition into fellowship training programs in psychiatry and surgery. METHODS: The authors conducted a mixed-methods study consisting of an online survey of IMG fellows and their supervisors in psychiatry or surgery fellowship training programs and individual interviews of IMG fellows. The survey assessed (a) fellows' and supervisors' perceptions on IMG challenges in clinical communication, health systems, and education domains and (b) past orientation initiatives. In the second phase of the study, IMG fellows were interviewed during the latter half of their fellowship training, and perceptions regarding orientation and adaptation to fellowship in Canada were assessed. Survey data were analyzed using descriptive and Mann-Whitney U statistics. Qualitative interviews were analyzed using grounded theory methodology. RESULTS: The survey response rate was 76% (35/46) and 69% (35/51) for IMG fellows and supervisors, respectively. Fellows reported the greatest difficulty with adapting to the hospital system, medical documentation, and balancing one's professional and personal life. Supervisors believed that fellows had the greatest difficulty with managing language and slang in Canada, the healthcare system, and an interprofessional team. In Phase 2, fellows generated themes of disorientation, disconnection, interprofessional team challenges, a need for IMG fellow resources, and a benefit from training in a multicultural setting. CONCLUSIONS: Our study results highlight the need for IMG specific orientation resources for fellows and supervisors. Maslow's Hierarchy of Needs may be a useful framework for understanding IMG training needs.

Interprofessional education for delirium care: a systematic review.

Recent delirium prevention and treatment guidelines recommend the use of an interprofessional team trained and competent in delirium care. We conducted a systematic review to identify the evidence for the value of interprofessional delirium education programs on learning outcomes. We searched several databases and the grey literature. Studies describing an education intervention, involving two or more healthcare professions and reporting on at least one learning outcome as classified by Kirkpatrick's evaluation framework were included in this review. Ten out of 633 abstracts reviewed met the study inclusion criteria. Several studies reported on more than one learning outcome. Two studies focused on learner reactions to interprofessional delirium education; three studies focused on learning outcomes (e.g. delirium knowledge); six studies focused on learner behavior in practice; and six studies reported on learning results (e.g. patient outcomes), mainly changes in delirium rates post-intervention. Studies reporting changes in patient outcomes following the delirium education intervention used an interprofessional practice (IPP) intervention in combination with interprofessional education (IPE). Our review of the limited evidence suggests that IPE programs may influence team and patient outcomes in delirium care. More systematic studies of the effectiveness of interprofessional delirium education interventions are needed.