Should We Still Have Bare-Metal Stents Available in Our Catheterization Laboratory?

The introduction of bare-metal stents (BMS) has represented a major advancement over plain old balloon angioplasty in the management of coronary artery disease. However, the high rates of target lesion revascularization associated with use of BMS have led to the development of drug-eluting stents, which require prolonged dual antiplatelet therapy due to the increased risk of late and very late stent thrombosis. The improvements in newer-generation drug-eluting stents have translated into better safety and efficacy compared with earlier generation and BMS, thus allowing shorter dual antiplatelet therapy duration. Here, we aim to provide reasons as to why we still need BMS in our cardiac catheterization laboratory.

Addressing the key communication barriers between microbiology laboratories and clinical units: a qualitative study

Background

Many countries are on the brink of establishing antibiotic stewardship programmes in hospitals nationwide. In a previous study we found that communication between microbiology laboratories and clinical units is a barrier to implementing efficient antibiotic stewardship programmes in Norway. We have now addressed the key communication barriers between microbiology laboratories and clinical units from a laboratory point of view.

Methods

Qualitative semi-structured interviews were conducted with 18 employees (managers, doctors and technicians) from six diverse Norwegian microbiological laboratories, representing all four regional health authorities. Interviews were recorded and transcribed verbatim. Thematic analysis was applied, identifying emergent themes, subthemes and corresponding descriptions.

Results

The main barrier to communication is disruption involving specimen logistics, information on request forms, verbal reporting of test results and information transfer between poorly integrated IT systems. Furthermore, communication is challenged by lack of insight into each other's area of expertise and limited provision of laboratory services, leading to prolonged turnaround time, limited advisory services and restricted opening hours.

Conclusions

Communication between microbiology laboratories and clinical units can be improved by a review of testing processes, educational programmes to increase insights into the other's area of expertise, an evaluation of work tasks and expansion of rapid and point-of-care test services. Antibiotic stewardship programmes may serve as a valuable framework to establish these measures.

The microINR portable coagulometer: analytical quality and user-friendliness of a PT (INR) point-of-care instrument

Regular measurement of prothrombin time as an international normalized ratio PT (INR) is mandatory for optimal and safe use of warfarin. Scandinavian evaluation of laboratory equipment for primary health care (SKUP) evaluated the microINR portable coagulometer (microINR^®) (iLine Microsystems S.L., Spain) for measurement of PT (INR). Analytical quality and user-friendliness were evaluated under optimal conditions at an accredited hospital laboratory and at two primary health care centres (PHCCs). Patients were recruited at the outpatient clinic of the Laboratory of Medical Biochemistry, St Olav's University Hospital, Trondheim, Norway (n = 98) and from two PHCCs (n = 88). Venous blood samples were analyzed under optimal conditions on the STA-R^®Evolution with STA-SPA + reagent (Stago, France) (Owren method), and the results were compared to capillary measurements on the microINR^®. The imprecision of the microINR^® was 6% (90% CI: 5.3-7.0%) and 6.3% (90% CI: 5.1-8.3) in the outpatient clinic and PHCC2, respectively for INR ≥2.5. The microINR^® did not meet the SKUP quality requirement for imprecision ≤5.0%. For INR <2.5 at PHCC2 and at both levels in PHCC1, CV% was ≤5.0. The accuracy fulfilled the SKUP quality goal in both outpatient clinic and PHCCs. User-friendliness of the operation manual was rated as intermediate, defined by SKUP as neutral ratings assessed as neither good nor bad. Operation facilities was rated unsatisfactory, and time factors satisfactory. In conclusion, quality requirements for imprecision were not met. The SKUP criteria for accuracy was fulfilled both at the hospital and at the PHCCs. The user-friendliness was rated intermediate.

[Comparative analysis of malaria detection ability of laboratories in Shanghai City from 2012 to 2015]

OBJECTIVE

To compare the application effects of three methods, namely microscopic examination, antigen detection (RDT) and nucleic acid test (PCR) in malaria detection between municipal and districts/counties centers for disease control and prevention in Shanghai, and analyze the malaria detection ability of the laboratories in Shanghai.

METHODS

The blood smears, whole blood samples, case review confirmation records and case data of malaria cases and suspected cases in Shanghai from 2012 to 2015 were collected by Shanghai Municipal Center for Disease Control and Prevention, and the detection results were analyzed and compared.

RESULTS

A total of 212 samples with complete data were submitted by all districts (counties) in Shanghai from 2012 to 2015, the samples submitted by Jinshan Districts were the most (41.98%), and among the first diagnosis hospitals, those submitted by the tertiary hospitals were the most (82.07%). The submitted samples in the whole year were increased gradually from January to October. All the 212 samples were detected by three methods (the microscopic examination, RDT and PCR) in the laboratory of Shanghai Municipal Center for Disease Control and Prevention, and 167 were tested and confirmed comprehensively as positives, accounting for 78.77%, and 45 were confirmed as negatives, accounting for 21.23%. The samples were detected by the method of microscopy and domestic RDT in the laboratories of the centers for disease control and prevention at district/county level, totally 153 were tested as positives, accounting for 72.17%, 41 were unclassified, accounting for 19.34%, 53 were negative, accounting for 25.00%, and 6 were undetected, accounting for 2.83%. The coincidence of microscopic examination between the report hospitals and the centers for disease control and prevention at district/county level was 78.16%, and the coincidence between centers for disease control and prevention at district/county level and municipal level was 93.20%. The utilization rate of RDT in the laboratory of district/county level was 73.58%. The coincidence of RDT tests between those domestic and imported was 93.59%. Compared with the detection results by municipal center for disease control and prevention, 37 samples were misjudged by the laboratories of district/county level. Almost all (99.37%) of the confirmed malaria cases were imported overseas, including Africa (85.44%), Asia (13.92%) and America (0.63%).

CONCLUSIONS

The surveillance after malaria elimination in Shanghai should be carried out by combining with different detection methods and resource integration.

Lab-in-a-Box

Objectives

Noncommunicable diseases, including malignancies, represent an increasing proportion of the global human disease burden, but low- and middle-income countries lack the necessary infrastructure to diagnose and treat the rising number of patients with cancer.

Methods

African Strategies for Advancing Pathology devised the lab-in-a-box to guide rapid deployment of anatomic pathologic services in sub-Saharan Africa.

Results

This framework defines essential elements of a laboratory network, providing the full spectrum of cancer care, and explores the many barriers to creating fully functional laboratory networks in resource-limited settings.

Conclusions

For global cancer care access and quality to advance, multiple stakeholders must commit to common goals and objectives and develop a comprehensive, sustainable system. African Strategies for Advancing Pathology will continue aligning stakeholders and advocating for meaningful policy changes to create positive, measurable, and long-lasting impact on global cancer care.

Comparability of Point-of-Care versus Central Laboratory Hemoglobin Determination in Emergency Patients at a Supra-Maximal Care Hospital

Fulfilling the requirements of point-of-care testing (POCT) training regarding proper execution of measurements and compliance with internal and external quality control specifications is a great challenge. Our aim was to compare the values of the highly critical parameter hemoglobin (Hb) determined with POCT devices and central laboratory analyzer in the highly vulnerable setting of an emergency department in a supra maximal care hospital to assess the quality of POCT performance. In 2548 patients, Hb measurements using POCT devices (POCT-Hb) were compared with Hb measurements performed at the central laboratory (Hb-ZL). Additionally, sub collectives (WHO anemia classification, patients with Hb <8 g/dl and suprageriatric patients (age >85y.) were analyzed. Overall, the correlation between POCT-Hb and Hb-ZL was highly significant (r = 0.96, p<0.001). Mean difference was -0.44g/dl. POCT-Hb values tended to be higher than Hb-ZL values (t(2547) = 36.1, p<0.001). Standard deviation of the differences was 0.62 g/dl. Only in 26 patients (1%), absolute differences >2.5g/dl occurred. McNemar´s test revealed significant differences regarding anemia diagnosis according to WHO definition for male, female and total patients (♂ p<0.001; ♀ p<0.001, total p<0.001). Hb-ZL resulted significantly more often in anemia diagnosis. In samples with Hb<8g/dl, McNemar´s test yielded no significant difference (p = 0.169). In suprageriatric patients, McNemar´s test revealed significant differences regarding anemia diagnosis according to WHO definition in male, female and total patients (♂ p<0.01; ♀ p = 0.002, total p<0.001). The difference between Hb-ZL and POCT-Hb with Hb<8g/dl was not statistically significant (<8g/dl, p = 1.000). Overall, we found a highly significant correlation between the analyzed hemoglobin concentration measurement methods, i.e. POCT devices and at the central laboratory. The results confirm the successful implementation of the presented POCT concept. Nevertheless some limitations could be identified in anemic patients stressing the importance of carefully examining clinically implausible results.

HLA compatibility assessment and management of highly sensitized patients under the new kidney allocation system (KAS): A 2016 status report from twelve HLA laboratories across the U.S

Twelve HLA laboratories were surveyed to assess the methods and operational issues involved to define highly sensitized patients and to assess HLA compatibility under the new kidney allocation system (KAS) in the U.S. All laboratories used single antigen bead assays both pre- and post-KAS to define both broad and allele-specific HLA antibodies. The methods and threshold used to list HLA unacceptable antigens in UNet for virtual crossmatch (vXM) and the criteria used for determining HLA compatibility varied among laboratories. Laboratories reported several limitations of the current assays including the accuracy of quantifiable antibody fluorescence values, inadequate coverage of common alleles on the bead panels, and challenges in calibrating the vXM. The new KAS has resulted in a significant surge of deceased donor organ offers requiring vXM evaluation under tight time constraints. In the post-KAS period, eight of twelve laboratories (67%) indicated that their center did not proceed to transplant based on vXM without a prospective lymphocyte crossmatch. In conclusion, HLA laboratories play a critical role in deceased donor allocation for highly sensitized patients under the new KAS. Significant opportunities exist to improve the methods used in the assessment of HLA compatibility to safely transplant highly sensitized patients.

A dedicated fungal culture medium is useful in the diagnosis of fungemia: a retrospective cross-sectional study

Background

Mortality for candidemia ranges from 15% to 35%. Current guidelines recommend inoculating blood into three aerobic and three anaerobic blood culture bottles when candidemia is suspected, without mention of a fungal blood culture bottle.

Objective

To determine the value of the BACTEC Myco/F Lytic blood culture media in the diagnosis of fungemia.

Methods

A two-year retrospective cross-sectional study was performed for patients who had fungemia with submitted BACTEC Plus Aerobic/F (Aer), BACTEC Plus Anaerobic/F (Anaer) or Myco/F Lytic (Myco) blood culture bottles.

Results

The detection rate of fungemia was 77.4% in 93 patients with contemporaneously submitted blood culture bottles when limited to only Aer/Anaer culture results. The detection rate improved significantly with the addition of the Myco culture bottle results (p<0.0001). A logistic regression model showed that Myco culture bottle submissions were less useful for patients with appropriate anti-fungal therapy administered within 48 hours [OR = 0.18, 95% CI = (0.06, 0.49), p = 0.001] and those with fungal growth detected within 48 hours [OR = 0.33, 95% CI = (0.12, 0.89), p = 0.001]. Among a subset of patients with concordant blood culture results, those with Myco culture bottles submission allowed earlier fungal detection and speciation by at least one day in 27.5% and 25.0% of the cases respectively.

Conclusion

Our study highlights the importance of a dedicated fungal blood culture when fungemia is clinically suspected. Nearly a quarter of fungemias may be missed if a fungal blood culture is not performed.

Significant Reduction in Preanalytical Errors for Nonphlebotomy Blood Draws After Implementation of a Novel Integrated Specimen Collection Module

OBJECTIVES

Most preanalytical errors at our institution occur during nonphlebotomy blood draws. We implemented an electronic health record (EHR), interfaced the EHR to the laboratory information system, and designed a new specimen collection module. We studied the effects of the new system on nonphlebotomy preanalytical errors.

METHODS

We used an electronic database of preanalytical errors and calculated the number and type of the most common errors in the emergency department (ED) and inpatient nursing for 3-month periods before (August-October 2014) and after (August-October 2015) implementation. The level of staff compliance with the new system was also assessed.

RESULTS

The average monthly preanalytical errors decreased significantly from 7.95 to 1.45 per 1,000 specimens in the ED (P < 0001) and 11.75 to 3.25 per 1,000 specimens in inpatient nursing (P < 0001). The rate of decrease was similar for mislabeled, unlabeled, wrong specimen received and no specimen received errors. Most residual errors (80% in the ED and 67% in inpatient nursing) occurred when providers did not use the new system as designed.

CONCLUSIONS

Implementation of a customized specimen collection module led to a significant reduction in preanalytical errors. Improved compliance with the system may lead to further reductions in error rates.

Laboratory Investigation of Myeloproliferative Neoplasms (MPNs): Recommendations of the Canadian Mpn Group

OBJECTIVES

To standardize diagnostic investigations for myeloproliferative neoplasms (MPNs) to increase homogeneity in patient care and to streamline diagnostic approaches in the most efficient and cost-effective manner.

METHODS

The development of Canadian expert consensus recommendations for the diagnosis of MPNs began with a review of the following: clinical evidence, daily practice, existing treatment guidelines, and availability of diagnostic tools. Each group member was assigned a specific topic, which they discussed with the entire group during several consensus meetings.

RESULTS

This document provides the Canadian MPN group's recommendations, proposed diagnostic algorithms, and background evidence upon which decisions were made.

CONCLUSIONS

Standardization of diagnostic investigations will increase homogeneity in patient care and provide a foundation for future clinical research in this rapidly evolving therapeutic area. Streamlining diagnostic approaches in the most efficient and cost-effective manner will also result in significant cost saving for the health care system.

[How to Interpret Data from Routine Laboratory Tests]

Routine laboratory tests are performed in almost all hospitals in the world. If you can fully interpret such routine laboratory tests, you can evaluate the general condition of patients in detail. In the reversed clinico- pathological conference (RCPC), we analyzed a patient's condition using only data from routine laboratory tests, as one of the most effective training methods to acquire the ability to interpret routine laboratory tests. In this RCPC, we discussed routine laboratory data from a patient who was transported by ambulance due to systemic weakness, and conducted interpretation of the data using the method of Shinshu University Hospital. At Shinshu University Hospital, we consider the time series results of the routine laboratory tests according to 13 steps, because our aim is to understand the patient's condition without oversight rather than to make a diagnosis. [Review].

Clinical Action Curves: Measuring the Magnitude of Physician Response to Abnormal Laboratory Results

OBJECTIVES

While reference limits are foundational to interpreting clinical laboratory tests, they may not correspond to the actual values triggering clinical response. We propose to measure this using clinical action curves, which plot test values against an indicator of clinical action.

METHODS

We selected repeat test ordering as a quantifiable, objective, useful measure that is readily calculable using available laboratory data. Using all results in Calgary in 2010-2011 for eight analytes, clinical action curves for each analyte were plotted as the relationship between index test value and retesting hazard, modeled using Cox proportional hazards with restricted cubic splines. Clinical action limits were defined where retesting hazard rose 38% above baseline (25%-50% considered).

RESULTS

In general, clinical action increased before the reference limits, and clinical action limits were narrower than reference limits. However, some reference limits showed no increased clinical action and may thus be ignored in practice.

CONCLUSIONS

Clinical action curves and limits provide practical, objective tools for describing physician responses to test values. Results suggest that many normal results are treated as abnormal and vice versa; such discrepancies require further scrutiny and ultimately reconciliation via altered reference ranges or altered practice patterns.

Clinical Evaluation of the Newly Developed HISCL-5000 Analyzer on Detection of Hepatitis B Virus Markers in West China Hospital

BACKGROUND

Detection of serum hepatitis B virus (HBV) markers is important for rapid screening and diagnosis of HBV infection. In this study, the newly launched HISCL-5000 analyzer (Sysmex Corporation, Kobe, Japan) was appraised in parallel with the MODULAR E170 (Roche Diagnostics, Penzberg, Germany), with regard to the detection of serological HBV markers in China for comparing and evaluating their results and capability.

METHODS

In this study, a total of 5,662 clinical serum samples were tested with the two automated systems. Among them, 1,266 samples were assessed for HBsAg, 1,000 for anti-HBs, 1,301 for HBeAg, 1,007 for anti-HBe, and 1,088 for anti-HBc. Reproducibility performance of HISCL-5000 was assayed four times per day for five days consecutively. For qualitative results between the two analyzers, the concordance rates and kappa coefficients were calculated. Spearman's rank correlation analysis was performed for quantitative results.

RESULTS

The HISCL-5000 detection mode showed excellent reproducibility with total CVs of less than 5.0%. Concordance between the two analyzers was 99.92% for HBsAg, 95.90% for anti-HBs, 100% for HBeAg, 99.30% for anti-HBe, and 98.62% for anti-HBc. Kappa values between the qualitative results of five HBV markers were 0.998, 0.906, 1.0, 0.983, and 0.969, respectively. For anti-HBs, linear regression analysis demonstrated a good correlation between HISCL-5000 and MODULAR E170 with an R2 value of 0.887. Spearman's correlation coefficients of 0.892, 0.644, -0.609, and -0.700 were observed for the other four markers, HBsAg, HBeAg, anti-H1Be, anti-HBc, respectively.

CONCLUSIONS

The newly launched HISCL-5000 displayed high agreement with the more matured MODULAR E170 on screening and diagnosing HBV infection in a clinical laboratory of West China Hospital.

Pneumatic tube system induced haemolysis: assessing sample type susceptibility to haemolysis

Background: The pneumatic tube system (PTS) has been implicated in inducing haemolysis. It is not known whether certain sample types are more susceptible to haemolysis than others. We assessed the level of haemolysis in commonly used sample types in the clinical biochemistry department when transported through the PTS.

Method: Blood was collected in pairs for different sample types and sent to the laboratory via the pneumatic tube or delivered by a porter. Haemolysis indices were measured spectrophotometrically and compared for each pair of sample type.

Results: Our results suggest that plain serum samples are more susceptible to haemolysis than the other sample types when sent through our PTS ( P <0.0001). Compared with serum with gel samples, plain serum samples are more prone to haemolysis ( P <0.001). This suggests that gel may confer some protection against haemolysis.

Conclusion: Different hospitals will have varying system configurations and use different sample types. We recommend that each hospital investigate their own system to assess whether haemolysis is a recurring problem in any of the sample types transported.

Process Optimization to Improve Immunosuppressant Drug Testing Turnaround Time

OBJECTIVES

Timely reporting of immunosuppressant (ISP) drug level results is needed for transplant patient management. This study characterized the local ISP testing process, identified bottlenecks and implemented process improvements to meet turnaround time requirements.

METHODS

Laboratory information time stamps, direct observation and discussion with staff were used to construct a value stream map of the ISP testing process to identify process bottlenecks. Improvements were implemented to attain the required turnaround time.

RESULTS

Baseline performance of the existing ISP process (seven weeks, n = 272 samples) indicated that only 28% of samples were reported by 2:00 pm Major bottlenecks were identified to be the analytical run schedule, instrument delays, difficulty identifying ISP samples at intake, and difficulty collecting specimens. Process changes resulted in a median of 76% samples reported by 2:00 pm

CONCLUSIONS

: Adjusting ISP collection and analysis processes improved the laboratory's ability to meet physician requested result reporting time of 2:00 pm.

A comparison of engineering controls for formaldehyde exposure during grossing activities in health care anatomic pathology laboratories

This article for the first time reports a large set of monitoring results for formaldehyde exposure during grossing activities in health care anatomic pathology laboratories, and compares the effectiveness of different local exhaust ventilation systems on the exposure. To control the confounding effects from grossing work load, sampling duration, and the sizes of specimens grossed, only 15-min short-term personal exposure samples collected during large tissue specimen grossing were used for the comparison of the effectiveness of these local exhaust systems. While we also collected long-term 8-hr time weighted average samples, these are not treated in this analysis. The systems examined were canopy receiving hoods, slot exhausts, and commercially available pre-manufactured backdraft grossing stations, both recirculating and ducted exhaust types. Out of over 2,000 personal short-term air samples, 307 samples from 163 surveys met the data selection criteria. Over a third of the data were less than the analytical laboratory limits of detection. Using the robust maximum likelihood estimation method for multiple limits of detection, the mean and geometric mean of the dataset for each type of local exhaust system were found to be less than the short-term personal exposure regulatory limit of 2 ppm. Nonparametric Wilcoxon rank-sum pairwise tests of five types of engineering controls showed a statistically significant difference among these controls, with the most effective being the manufactured backdraft grossing stations ducted to the outside, and the least effective being canopy exhaust systems and manufactured filtered recirculating grossing stations. Finally, exposure with each of the major engineering control types was rated by the American Industrial Hygiene Association exposure control rating scheme.

Providing a quality service: direct referral from the cytology laboratory to the colposcopy clinic

Objectives: To compare the time taken for the referral process and the accuracy of referrals before and after a process review and the introduction of a system of direct referral from the cytology laboratory to the colposcopy clinic.

Setting: The colposcopy service in a large teaching hospital in Teesside.

Methods: Data on time points within the referral process and smear histories were collected. Data on time points were obtained retrospectively from the case-notes from before the new system of referral ('pre' group) and from an electronic database after the changes ('post' group). Smear histories were retrieved from the cytology database.

Results: The overall time that patients waited from the time the smear was taken until the time they were seen in the colposcopy clinic was significantly reduced. The median time between smear and colposcopy decreased from 92.5 days (range 35−254 days) in the 'pre' group to 33 days (range 13−43 days) in the 'post' group ( P=0.0001). The median time taken from the smear report being issued until the report arrived in the colposcopy clinic was 14 days (range 4−123 days) in the 'pre' group, compared with two days (range 0−17 days) in the 'post' group ( P=0.0001). There was a significant reduction in the number of inaccurate referrals in the 'post' group compared with the 'pre' group ( P=0.02).

Conclusions: Direct referral significantly reduces the time patients wait for colposcopy appointments and improves the accuracy of referrals.

[Current Status and Issues of Clinical Laboratory Testing Expanding into Health Care: How to Challenge Experts of Laboratory Medicine -Remark of Moderators.]

Point-of-Care Testing (POCT) has been increasingly implemented in healthcare, on the basis of advances in analysis and information technologies. Wherever POCT is implemented, it needs to be properly and safe- ly performed. However, a concern has been raised that it is preformed without training and support from the clinical laboratory and, thus, testing reliability and patient safety are not sufficiently ensured. Laboratory professionals and experts are expected to play an important role in the solution of this issue, through provid- ing guidance and support in the proper implementation and patient safety of POCT. Hence, this symposium was organized to summarize current situations and issues of POCT expanding into health care, the communi- ty, and home, and to clarify the way to challenge them as laboratory professionals for increased reliability and confidence on performing POCT, contributing to the cost-effectiveness and quality of health-care services.

Multicenter study of autoverification methods of hematology analysis

This study was designed to establish and validate a set of autoverification methods for hematology analysis. One thousand and twenty-four samples were selected from Shanghai Ruijin Hospital and 999 from Beijing Hospital, China. False positive, false negative and autoverification pass rates were verified and the rules were then adjusted and confirmed according to the verification results. After confirmation, at least 10,000 sample cases were selected from Shanghai Ruijin Hospital, Beijing Hospital and China Armed Police General Hospital and checked automatically. The differences in the autoverification pass rate and average report delivery time before and after the application of the autoverification methods were compared between the three hospitals. Preliminary validation results showed that the false negative rates of the Shanghai Ruijin Hospital and Beijing Hospital were less than 2%. The false positive rates of these two hospitals were high, close to 18%. After rule adjustment, the false negative rate was basically the same as before adjustment, but the false positive rate declined obviously while the pass rate of autoverification improved significantly. The autoverification pass rates of the three hospitals were 76.4%, 85.1% and 84.2%, respectively. The turnover time (TAT, time from receipt of sample to report of the result) of the three hospitals decreased by 4.1 min, 8.8 min and 10.2 min, respectively. Autoverification systems using a Mindray BC-6800 auto hematology analyzer and labXpert were confirmed as being effective in reducing TAT and enhancing working efficiency on the premise of ensuring low false negative rate.

Resident reflections on end-of-life education: a mixed-methods study of the 3 Wishes Project

OBJECTIVE

The objectives of this study were to describe residents' experiences with end-of-life (EOL) education during a rotation in the intensive care unit (ICU), and to understand the possible influence of the 3 Wishes Project.

DESIGN

We enrolled dying patients, their families and 1-3 of their clinicians in the 3 Wishes Project, eliciting and honouring a set of 3 wishes to bring peace to the final days of a critically ill patient's life, and ease the grieving process for families. We conducted semistructured interviews with 33 residents who had cared for 50 dying patients to understand their experiences with the project. Interviews were recorded, transcribed verbatim, then analysed using a qualitative descriptive approach.

SETTING

21-bed medical surgical ICU in a tertiary care, university-affiliated hospital.

RESULTS

33 residents participated from internal medicine (24, 72.7%), anaesthesia (8, 24.2%) and laboratory medicine (1, 3.0%) programmes in postgraduate years 1-3. 3 categories and associated themes emerged. (1) EOL care is a challenging component of training in that (a) death in the ICU can invoke helplessness, (b) EOL education is inadequate, (c) personal connections with dying patients is difficult in the ICU and (d) EOL skills are valued by residents. (2) The project reframes the dying process for residents by (a) humanising this aspect of practice, (b) identifying that family engagement is central to the dying process, (c) increasing emotional responsiveness and (d) showing that care shifts, not stops. (3) The project offers experiential education by (a) intentional role modelling, (b) facilitating EOL dialogue, (c) empowering residents to care in a tangible way and (d) encouraging reflection.

CONCLUSIONS

For residents, the 3 Wishes Project integrated many forms of active learning for residents. Practice-based rather than classroom-based programmes may engage trainees to develop EOL skills transferable to other settings.