A mixed-methods study of organ donation in the intensive care unit: 22 actionable practices to improve organ donation.

PURPOSE: Rates of organ donation vary between otherwise comparable intensive care units (ICUs) suggesting that the process of donation must vary between ICUs. The purpose of this study was to describe the process of organ donation from the perspective of ICU staff, identify important drivers of successful donation, and develop strategies to improve the process of donation. METHODS: We conducted qualitative interviews with 32 ICU staff, including physicians, nurses, and respiratory therapists, using an interview guide developed from previous studies on organ donation. Using a qualitative descriptive approach, we coded interviews using qualitative content analysis. We integrated findings from the interviews in a mixed-methods analysis with previously published data from a document analysis and cross-sectional survey to identify practices that may enhance organ donation in the ICU. RESULTS: Five major themes important to the organ donation process emerged from the interviews: i) staff relationship with organ donation coordinators; ii) standardized processes; iii) ICU staff beliefs; iv) integration of donation and high quality end-of-life care; v) feedback and staff support. In the mixed-methods analysis, we identified 22 actionable practices to enhance the process of organ donation in the ICU. CONCLUSION: Incorporating the perspectives of ICU staff, we were able to identify 22 practice changes that may have a significant cumulative impact on donation outcomes. Future research is required to evaluate whether these findings account for the variability of donation rates between otherwise comparable ICUs.

Understanding why patients with immune thrombocytopenia are deeply divided on splenectomy.

BACKGROUND: Splenectomy is an effective treatment for chronic immune thrombocytopenia (ITP); however, patients' willingness to accept splenectomy is variable. OBJECTIVE: To explore why some ITP patients accepted splenectomy when recommended by their physician while others refused. DESIGN: Qualitative descriptive study using one-to-one, in-depth patient interviews and a team-based approach to thematic analysis. RESULTS: Of 25 patients interviewed, 15 refused splenectomy and 10 accepted and were awaiting surgery. Themes about the influences on splenectomy decision making that emerged from patient interviews were (i) the perceived impact of ITP on quality of life, (ii) patients' view of splenectomy as a last resort treatment, (iii) patients' interpretations of the rates of treatment success and failure and (iv) a perceived lack of familiarity about ITP. Patients who accepted splenectomy perceived their disease as having a negative impact on their quality of life, whereas patients who refused felt their situation was not severe enough to warrant surgery. Patients developed their own experiential interpretations of the success rates of splenectomy quoted to them. A general lack of awareness of the clinical impact of ITP and its cause was identified by patients as barriers to choosing splenectomy. CONCLUSIONS: Patients' disease experience, perceptions of the lack of treatment alternatives, interpretations of treatment success and failure rates and a general lack of awareness about ITP influenced treatment choice. This study represents a first step towards contextualizing treatment decision making in ITP, focusing on patient preferences and values.

A new tool to assess bleeding severity in patients with chemotherapy-induced thrombocytopenia.

BACKGROUND: Current scales to measure bleeding in clinical trials are inadequate. The aim of this study was to develop a simple, valid, and reliable measurement tool to categorize the severity of bleeding in patients with chemotherapy-induced thrombocytopenia (CIT). STUDY DESIGN AND METHODS: Measurement theory was used to develop the Bleeding Severity Measurement Scale (BSMS) in four steps: 1) identification of the patient population, 2) item generation and reduction, 3) reviewing the items and formatting the scale, and 4) evaluation of psychometric properties. Feasibility was tested in a pilot study. Content and face validity were assessed by expert review. Psychometric evaluation included determination of intra- and interrater reliability and construct and criterion validity. RESULTS: The final BSMS defined two grades of bleeding: not clinically significant (Grade 1) and clinically significant (Grade 2). Grade 2 bleeds were defined as bleeds resulting in morbidity, requiring interventions, or directly causing death. The BSMS had excellent interrater (intraclass correlation coefficient [ICC], 0.80) and intrarater (ICC, 1.0) reliability and good construct and criterion validity. The BSMS distinguished between patients with different bleeding severities. CONCLUSION: Using rigorous methods, we designed a simple bleeding assessment tool with excellent psychometric properties for patients with CIT. Use of this scale in clinical trials should provide valid and reliable assessments of bleeding.

Do expert assessments converge? An exploratory case study of evaluating and managing a blood supply risk.

BACKGROUND: Examining professional assessments of a blood product recall/withdrawal and its implications for risk and public health, the paper introduces ideas about perceptions of minimal risk and its management. It also describes the context of publicly funded blood transfusion in Canada and the withdrawal event that is the basis of this study. METHODS: Interviews with 45 experts from administration, medicine, blood supply, laboratory services and risk assessment took place using a multi-level sampling framework in the aftermath of the recall. These experts either directly dealt with the withdrawal or were involved in the management of the blood supply at the national level. Data from these interviews were coded in NVivo for analysis and interpretation. Analytically, data were interpreted to derive typifications to relate interview responses to risk management heuristics. RESULTS: While all those interviewed agreed on the importance of patient safety, differences in the ways in which the risk was contextualized and explicated were discerned. Risk was seen in terms of patient safety, liability or precaution. These different risk logics are illustrated by selected quotations. CONCLUSIONS: Expert assessments did not fully converge and it is possible that these different risk logics and discourses may affect the risk management process more generally, although not necessarily in a negative way. Patient safety is not to be compromised but management of blood risk in publicly funded systems may vary. We suggest ways of managing blood risk using formal and safety case approaches.

A review of randomized controlled trials comparing the effectiveness of hand held computers with paper methods for data collection.

BACKGROUND: Handheld computers are increasingly favoured over paper and pencil methods to capture data in clinical research. METHODS: This study systematically identified and reviewed randomized controlled trials (RCTs) that compared the two methods for self-recording and reporting data, and where at least one of the following outcomes was assessed: data accuracy; timeliness of data capture; and adherence to protocols for data collection. RESULTS: A comprehensive key word search of NLM Gateway's database yielded 9 studies fitting the criteria for inclusion. Data extraction was performed and checked by two of the authors. None of the studies included all outcomes. The results overall, favor handheld computers over paper and pencil for data collection among study participants but the data are not uniform for the different outcomes. Handheld computers appear superior in timeliness of receipt and data handling (four of four studies) and are preferred by most subjects (three of four studies). On the other hand, only one of the trials adequately compared adherence to instructions for recording and submission of data (handheld computers were superior), and comparisons of accuracy were inconsistent between five studies. CONCLUSION: Handhelds are an effective alternative to paper and pencil modes of data collection; they are faster and were preferred by most users.

Perspectives on work (re)entry for persons with disabilities: implications for clinicians.

Despite the prevalence of government funding to support employment opportunities for persons with disabilities, real jobs for this population still appear to be elusive. McMaster University researchers examined how six stakeholder groups defined workplace (re)entry success for persons with disabilities. Focus groups and individual interviews were conducted with representation from employers, unions, persons with disabilities, co-workers, supervisors and human resource departments. Participants numbered 86 and the average age was 42. Participant comments provided the researchers with rich data related to the study objectives. Success was perceived as not only a match between the employee and the job but also a win-win for employer and employer, a uniquely defined set of circumstances based on the specific individual and their environment as well as respect for the individual's dignity and quality of life. This article discusses the study and its outcomes and highlights implications for clinicians.

Benchmarking: applications to transfusion medicine.

Benchmarking is as a structured continuous collaborative process in which comparisons for selected indicators are used to identify factors that, when implemented, will improve transfusion practices. This study aimed to identify transfusion medicine studies reporting on benchmarking, summarize the benchmarking approaches used, and identify important considerations to move the concept of benchmarking forward in the field of transfusion medicine. A systematic review of published literature was performed to identify transfusion medicine-related studies that compared at least 2 separate institutions or regions with the intention of benchmarking focusing on 4 areas: blood utilization, safety, operational aspects, and blood donation. Forty-five studies were included: blood utilization (n = 35), safety (n = 5), operational aspects of transfusion medicine (n = 5), and blood donation (n = 0). Based on predefined criteria, 7 publications were classified as benchmarking, 2 as trending, and 36 as single-event studies. Three models of benchmarking are described: (1) a regional benchmarking program that collects and links relevant data from existing electronic sources, (2) a sentinel site model where data from a limited number of sites are collected, and (3) an institutional-initiated model where a site identifies indicators of interest and approaches other institutions. Benchmarking approaches are needed in the field of transfusion medicine. Major challenges include defining best practices and developing cost-effective methods of data collection. For those interested in initiating a benchmarking program, the sentinel site model may be most effective and sustainable as a starting point, although the regional model would be the ideal goal.

Understanding the meaning of permanent deferral for blood donors.

BACKGROUND: To ensure the safety of the blood supply, it is necessary to permanently defer blood donors with a repeat-reactive transmissible disease test result. The purpose of this study was to explore the permanent deferral experience from the donor's perspective. STUDY DESIGN AND METHODS: A qualitative study was conducted with donors from two Canadian blood centers who received written notice of permanent deferral in six deferral categories: human immunodeficiency virus-1 and/or -2 and hepatitis C virus and/or hepatitis B virus (negative, indeterminate, or positive). Telephone interviews were conducted with a semistructured questionnaire. Interview transcripts were coded and central themes were identified. The data were then modeled to illustrate the relationships between the themes. RESULTS: Twenty-eight permanently deferred donors were interviewed and described a variety of negative emotional and behavioral responses including confusion, shock, disbelief, panic, fear, anger, stigmatization, and loss. A conceptual model was developed illustrating the phases that a deferred donor goes through (identifying as a healthy donor, receiving notification, experiencing emotional and behavioral reactions, trying to make sense of what happened, and taking action) as they travel along the path to becoming either a "reconciled" or "not reconciled" permanently deferred donor. Participants offered constructive suggestions for modifying the notification process including revising the letter, providing follow-up, and educating family physicians. CONCLUSIONS: To our knowledge, this is the first study to use qualitative research methodology to explore the experience of permanent blood donor deferral. More studies are needed to validate and expand this preliminary conceptual model.

Bleeding risks associated with inheritance of the Quebec platelet disorder.

Quebec platelet disorder (QPD) is an autosomal dominant bleeding disorder associated with increased urokinase-type plasminogen activator in platelets and alpha-granule protein degradation. To determine bleeding risks and common manifestations of QPD, a history questionnaire was developed and administered to 127 relatives in a family with QPD. Data entry was done blinded to affected and unaffected status, determined by assays for platelet urokinase-type plasminogen activator (u-PA) and fibrinogen degradation. Odds ratios (ORs), with 95% confidence intervals (CIs), were determined for items queried. Summative bleeding scores for each individual were calculated using items with OR more than 1. Mean ages (34 years; range, 1-89 years) were similar for affected (n = 23) and unaffected (n = 104) family members. Affected individuals had higher mean bleeding scores (P <.0001) and a much higher likelihood (OR > 20) of having bleeding that led to lifestyle changes, bruises that spread lower or as large or larger than an orange or both, joint bleeds, bleeding longer than 24 hours after dental extractions or deep cuts, and received or been recommended other treatments (fibrinolytic inhibitors) for bleeding. Individuals with QPD and exposure(s) to hemostatic challenges had experienced excessive bleeding only when fibrinolytic inhibitors had not been used. These data illustrate that QPD is associated with increased risks of bleeding that can be modified by fibrinolytic inhibitors.