COMmunication with Families regarding ORgan and Tissue donation after death in intensive care (COMFORT): protocol for an intervention study.

BACKGROUND: Discussing deceased organ donation can be difficult not only for families but for health professionals who initiate and manage the conversations. It is well recognised that the methods of communication and communication skills of health professionals are key influences on decisions made by families regarding organ donation. METHODS: This multicentre study is being performed in nine intensive care units with follow-up conducted by the Organ and Tissue Donation Service in New South Wales (NSW) Australia. The control condition is pre-intervention usual practice for at least six months before each site implements the intervention. The COMFORT intervention consists of six elements: family conversations regarding offers for organ donation to be led by a "designated requester"; family offers for donation are deferred to the designated requester; the offer of donation is separated from the end-of-life discussion that death is inevitable; it takes place within a structured family donation conversation using a "balanced" approach. Designated requesters may be intensivists, critical care nurses or social workers prepared by attending the three-day national "Family Donation Conversation" workshops, and the half-day NSW Simulation Program. The design is pre-post intervention to compare rates of family consent for organ donation six months before and under the intervention. Each ICU crosses from using the control to intervention condition after the site initiation visit. The primary endpoint is the consent rate for deceased organ donation calculated from 140 eligible next of kin families. Secondary endpoints are health professionals' adherence rates to core elements of the intervention; identification of predictors of family donation decision; and the proportion of families who regret their final donation decision at 90 days. DISCUSSION: The pragmatic design of this study may identify 'what works' in usual clinical settings when requesting organ donation in critical care areas, both in terms of changes in practice healthcare professionals are willing and able to adopt, and the effect this may have on desired outcomes. The findings of this study will be indicative of the potential benefits of the intervention and be relevant and transferrable to clinical settings in other states and countries. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000815763 (24 July 2013). ClinicalTrials.gov: NCT01922310 (14 August 2013) (retrospectively registered).

Simulation-Based Communication Skills Training for Experienced Clinicians to Improve Family Conversations About Organ and Tissue Donation.

INTRODUCTION: The approach, communication skills, and confidence of clinicians responsible for raising deceased organ donation may influence families' donation decisions. The aim of this study was to increase the preparedness and confidence of intensive care clinicians allocated to work in a "designated requester" role. DESIGN: We conducted a posttest evaluation of an innovative simulation-based training program. Simulation-based training enabled clinicians to rehearse the "balanced approach" to family donation conversations (FDCs) in the designated requester role. Professional actors played family members in simulated clinical settings using authentic scenarios, with video-assisted reflective debriefing. Participants completed an evaluation after the workshop. Simple descriptive statistical analysis and content analysis were performed. RESULTS: Between January 2013 and July 2015, 25 workshops were undertaken with 86 participants; 82 (95.3%) returned evaluations. Respondents were registered practicing clinicians; over half (44/82; 53.7%) were intensivists. Most attended a single workshop. Evaluations were overwhelmingly positive with the majority rating workshops as outstanding (64/80; 80%). Scenario fidelity, competence of the actors, opportunity to practice and receive feedback on performance, and feedback from actors, both in and out of character, were particularly valued. Most (76/78; 97.4%) reported feeling more confident about their designated requester role. DISCUSSION: Simulation-based communication training for the designated requester role in FDCs increased the knowledge and confidence of clinicians to raise the topic of donation.

A Comparison of Recruitment Methods for an mHealth Intervention Targeting Mothers: Lessons from the Growing Healthy Program.

BACKGROUND: Mobile health (mHealth) programs hold great promise for increasing the reach of public health interventions. However, mHealth is a relatively new field of research, presenting unique challenges for researchers. A key challenge is understanding the relative effectiveness and cost of various methods of recruitment to mHealth programs. OBJECTIVE: The objectives of this study were to (1) compare the effectiveness of various methods of recruitment to an mHealth intervention targeting healthy infant feeding practices, and (2) explore factors influencing practitioner referral to the intervention. METHODS: The Growing healthy study used a quasi-experimental design with an mHealth intervention group and a concurrent nonrandomized comparison group. Eligibility criteria included: expectant parents (>30 weeks of gestation) or parents with an infant <3 months old, ability to read and understand English, own a mobile phone, ≥18 years old, and living in Australia. Recruitment to the mHealth program consisted of: (1) practitioner-led recruitment through Maternal and Child Health nurses, midwives, and nurses in general practice; (2) face-to-face recruitment by researchers; and (3) online recruitment. Participants' baseline surveys provided information regarding how participants heard about the study, and their sociodemographic details. Costs per participant recruited were calculated by taking into account direct advertising costs and researcher time/travel costs. Practitioner feedback relating to the recruitment process was obtained through a follow-up survey and qualitative interviews. RESULTS: A total of 300 participants were recruited to the mHealth intervention. The cost per participant recruited was lowest for online recruitment (AUD $14) and highest for practice nurse recruitment (AUD $586). Just over half of the intervention group (50.3%, 151/300) were recruited online over a 22-week period compared to practitioner recruitment (29.3%, 88/300 over 46 weeks) and face-to-face recruitment by researchers (7.3%, 22/300 over 18 weeks). No significant differences were observed in participant sociodemographic characteristics between recruitment methods, with the exception that practitioner/face-to-face recruitment resulted in a higher proportion of first-time parents (68% versus 48%, P=.002). Less than half of the practitioners surveyed reported referring to the program often or most of the time. Key barriers to practitioner referral included lack of time, difficulty remembering to refer, staff changes, lack of parental engagement, and practitioner difficulty in accessing the app. CONCLUSIONS: Online recruitment using parenting-related Facebook pages was the most cost effective and timely method of recruitment to an mHealth intervention targeting parents of young infants. Consideration needs to be given to addressing practitioner barriers to referral, to further explore if this can be a viable method of recruitment.

Education and training methods for healthcare professionals to lead conversations concerning deceased organ donation: An integrative review.

OBJECTIVES: To determine which training methods positively influenced healthcare professionals' communication skills and families' deceased organ donation decision-making. METHODS: An integrative review using systematic methods and narrative synthesis for data analysis. Electronic databases of PubMed, Cumulative Index to Nursing and Allied Health Literature (EBSCO), Embase (OVID) and ProQuest Dissertations & Theses Global, were searched between August 1997 and March 2020, retrieving 1019 papers. Included papers (n = 14) were appraised using the Medical Education Research Study Quality Instrument. RESULTS: Training programmes offered theory, experiential learning, feedback and debriefing including self-reflection, the opportunity to role-play and interact with simulated participants within realistic case scenarios. Programmes reported observed and self-rated improvements in communication learning and confidence. The methodological quality score averaged 13, (72% of maximum); few studies used an experimental design, examined behavioural change or families' perspectives. Weak evidence suggested training could increase organ donation authorisation/consent rates. CONCLUSIONS: Multiple training strategies are effective in improving interprofessional healthcare professionals' confidence and learning of specialised communication. Methodological limitations restricted the ability to present definitive recommendations and further research is warranted, inclusive of family decision-making experiences. PRACTICE IMPLICATIONS: Learning of specialised communication skills is enhanced by using multiple training strategies, including role-play and debriefing.

A pilot study of sound levels in an Australian adult general intensive care unit.

High technology and activity levels in the intensive care unit (ICU) lead to elevated and disturbing sound levels. As noise has been shown to affect the ability of patients to rest and sleep, continuous sound levels are required during sleep investigations. The aim of this pilot study was to develop a robust protocol to measure continuous sound levels for a larger more substantive future study to improve sleep for the ICU patient. A review of published studies of sound levels in intensive care settings revealed sufficient information to develop a study protocol. The study protocol resulted in 10 usable recordings out of 11 attempts to collect pilot data. The mean recording time was 17.49 +/- 4.5 h. Sound levels exceeded recommendations made by the World Health Organization (WHO) for hospitals. The mean equivalent sound level (LAeq) was 56.22 +/- 1.65 dB and LA90 was 46.8 +/- 2.46 dB. The data reveal the requirement for a noise reduction program within this ICU.

Suicide in older people, attitudes and knowledge of emergency nurses: A multi-centre study.

INTRODUCTION: Suicide in older people is a public health concern. Emergency nurses are ideally placed to identify suicide risk. Therefore, the aim of this research was to explore emergency nurses' knowledge, confidence and attitudes about suicide in older people. METHODS: This descriptive exploratory study was conducted in four emergency departments in Sydney, Australia. Data were collected using a 28-item survey from a convenience sample of emergency nurses. Descriptive quantitative statistics and conventional content analysis were performed. Ethics approval was provided. RESULTS: The response rate was 58% (n = 136); the majority were female with an average of seven years emergency experience. The majority (n = 124, 91%) reported that they frequently managed suicidal behaviour and recognized suicide as a common event (80%). 51% (n = 69) recognized that suicide was a common event for older people. Only 16% (n = 22) reported receiving suicide prevention training with 11% feeling confident in managing suicidal behaviour. CONCLUSION: The findings contribute to the discourse on how suicide in older people is recognised by emergency nurses. Few nurses considered it a problem for older people and were not confident about their knowledge. There is a need for suicide prevention training as a priority particularly to identify risks in older people.

Implications for Australian practice of North American guidelines for the support of the family in patient-centred intensive care.

Patient-centred care, in which health care professionals inform patients and families, maintain active involvement in decision making, coordinate care across disciplines, provide families with physical comfort and emotional support and ensure care is culturally sensitive, is recommended over clinician- or disease-centred care for better patient outcomes. Patients in intensive care are often too ill to participate in communication and decision making, so the patient's family should be involved in communication and decision making about the patient's care. The Society of Critical Care Medicine published clinical practice guidelines for the support of the family in the patient-centred intensive care unit. The purpose of this paper is to assess whether the 42 recommendations in the guidelines are valid and applicable in Australia. We used a recognised framework for evaluation of clinical practice guidelines. It was found that the guidelines were developed systematically using accepted methods of guideline development as much as possible. An extensive literature review was conducted and publications containing all levels of evidence were considered for inclusion. There were some weaknesses in the guideline development, especially lack of consultation with patients and families and a lack of high-level evidence, however the authors have provided comprehensive recommendations to guide all aspects of patient-centred care. We conclude that the recommendations are largely applicable to the patients and families receiving treatment and support within intensive care units in Australia. Where strong evidence is lacking, the recommendations should be a stimulus to conduct studies that test interventions that may benefit intensive care patients, their families, and intensive care staff.

Communication with Families Regarding Organ and Tissue Donation after Death in Intensive Care (COMFORT): a multicentre before-and-after study.

OBJECTIVE: To implement a best-practice intervention offering deceased organ donation, testing whether it increased family consent rates. DESIGN: A multicentre before-and-after study of a prospective cohort compared with pre-intervention controls. SETTING: Nine Australian intensive care units. PARTICIPANTS: Families and health care professionals caring for donor-eligible patients without registered donation preferences or aged ≤ 16 years. INTERVENTION: A multicomponent intervention including offers of deceased organ donation from specially trained designated requesters using a structured conversation separate to end-of-life discussions. MAIN OUTCOME MEASURE: Proportion of families consenting to organ donation. RESULTS: Consent was obtained in 87/164 cases (53%) during the intervention period compared with 14/25 cases (56%) pre-intervention (P = 0.83). The odds ratio (OR) of obtaining consent during the intervention period relative to preintervention was 1.13 (95% CI, 0.48-2.63; P = 0.78). During the intervention period, designated requesters obtained consent in 55/98 cases (56%), compared with 32/66 cases (48%) in which the medical team managing patient care raised donation (P = 0.34). Factors independently associated with increased consent were: family-raised organ donation (OR, 4.34; 95% CI, 1.79-10.52; P = 0.001), presence of an independent designated requester (OR, 3.84; 95% CI, 1.35- 10.98; P = 0.012), and multiple donation conversations per case (OR, 3.35; 95% CI, 1.93-5.81; P < 0.001). Consent decreased when patients were of non-Christian religion (OR, 0.18; 95% CI, 0.04-0.91; P = 0.038) and end-of-life and donation meetings were separate (OR, 0.38; 95% CI, 0.16-0.89; P = 0.026). CONCLUSION: Implementation of a multicomponent intervention did not increase consent rates for organ donation, although some components of the intervention exerted significant effect. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12613000815763. ClinicalTrials.gov: NCT01922310.

Antimicrobial prescription patterns and ventilator associated pneumonia: findings from a 10-site prospective audit.

OBJECTIVE: To examine anti-microbial prescribing practices associated with ventilator-associated pneumonia from data gathered during an audit of practice and outcomes in intensive care units (ICUs) in a previously published study. RESULTS: The patient sample of 169 was 65% male with an average age of 59.7 years, a mean APACHE II score of 20.6, and a median ICU stay of 11 days. While ventilator-associated pneumonia was identified using a specific 4-item checklist in 29 patients, agreement between the checklist and independent physician diagnosis was only 17%. Sputum microbe culture reporting was sparse. Approximately 75% of the sample was administered an antimicrobial (main indications: lung infection [54%] and prophylaxis [11%]). No clinical justification was documented for 20% of prescriptions. Piperacillin/tazobactam was most frequently prescribed (1/3rd of all antimicrobial prescriptions) with about half of those for prophylaxis. Variations in prescribing practices were identified, including apparent gaps in antimicrobial stewardship; particularly in relation to prescribing for prophylaxis and therapy de-escalation. Sputum microbe culture reports for VAP did not appear to contribute to prescribing decisions but physician suspicion of lung infection and empiric therapy rather than ventilator-associated pneumonia criteria and guideline concordance.

Emergency department presentations by older people for mental health or drug and alcohol conditions: A multicentre retrospective audit.

PURPOSE: Emergency department presentations by older people associated with mental health and drug and alcohol related conditions are increasing. However, the characteristics of presentations by older people in Australia are largely unknown. The aim of this research was to explore the characteristics of older people presenting with mental health and drug and alcohol conditions. PROCEDURES: We used a retrospective electronic medical record audit to explore all emergency department presentations by older people 65 years and over for mental health and drug and alcohol related conditions over a 12 month period. Data were described using descriptive statistics. FINIDNGS: There were 40,093 presentations; 2% (n=900) were related to mental health or drug and alcohol related conditions. Presentations were mainly associated with primary mental or medical symptoms. The majority were female (n=471; 53%). Predominate conditions were cognitive impairment (n=234; 26%) and affective disorders (n=233; 26.0%). Sixty-three percent of patients were admitted to a hospital ward. Over the study period 106 patients (242 episodes of care) represented. PRINCIPLE CONCLUSIONS: Given the ageing population and increasing prevalence for mental health and drug and alcohol conditions, strategies are required to better recognise these conditions to reduce the burden on the health care system and improve health for older people.