Adherence to guidelines for the management of donors after brain death

Stepwise development of a quality assessment instrument for the medicines' pathway in nursing homes

BACKGROUND

Quality of care in nursing homes (NHs), and especially the quality of the medicines' pathway, remains a concern.

OBJECTIVES

To develop a quality assessment instrument to support NHs to evaluate the quality of their medicines' pathway, and to formulate recommendations for its implementation.

METHODS

A stepwise approach was used. First, a performance questionnaire for coordinating physicians, pharmacists and head nurses was developed, alongside a set of quality indicators (QIs). Next, a feasibility study regarding the QIs was performed in 4 NHs, followed by two pilot studies to optimize the instrument (in 14 and 9 NHs, respectively). Focus groups were held to formulate recommendations for instrument implementation.

RESULTS

The QI feasibility and first pilot study showed that the clarity and feasibility of QIs was insufficient. All QIs were therefore integrated in the performance questionnaire. The first pilot study also showed low response rates for certain questions in the performance questionnaire and resulted in a revision of questions with the aim to target the right type of healthcare professional, including quality coordinators and general practitioners. The final instrument targets all involved healthcare professionals (i.e. coordinating physicians, pharmacists, head nurses, general practitioners, and quality coordinators), and applies a sequential approach: a quick scan to set priorities, followed by a detailed scan to detect specific working points. The second pilot study showed appreciation for this approach. Last, five recommendations were made to promote the instrument's implementation.

CONCLUSIONS

A series of feasibility and pilot studies allowed the stepwise optimization of a quality assessment instrument for the medicines' pathway in NHs and resulted in modifications to improve its clarity and feasibility. Participants' recommendations will promote the successful implementation of the quality assessment instrument.

How patient-centered is education and counseling of patients treated with oral anticancer drugs? A multicenter cross-sectional study

OBJECTIVE

In this multicenter cross-sectional study, the quality of patient-centered education and counseling for patients treated with oral anticancer drugs was examined.

METHODS

The CONTACT-Patient-Centered Care Questionnaire was administered to 266 patients, recruited in 11 Flemish hospitals. The questionnaire consists of 80 items, each evaluating the degree of performance of a key element in patient-centered education and counseling.

RESULTS

In total, 15 key elements were seriously underperformed (degree of performance < 50%). Elements regarding adherence monitoring, specific topics in patient education, and involvement of the community pharmacist and home care nurse received a very low score. Only six key elements were systematically performed (degree of performance ≥ 90%), among which the elements on communication style and involvement of the general practitioner.

CONCLUSION

This study uncovered three major gaps in patient-centered education and counseling of patients on oral anticancer drugs: unmet patient information needs due to shortcomings in patient education, inadequate adherence monitoring, and lacking collaboration with community pharmacists and home care nurses.

PRACTICE IMPLICATIONS

This study highlights the need for interdisciplinary and patient-centered education and counseling of patients using OACD, including all key stakeholders: physicians, nurses, hospital pharmacists, general practitioners, community pharmacist and home care nurses.

Worldwide management of donors after neurological death: a systematic review and narrative synthesis of guidelines

OBJECTIVE

The objectives of this study were to systematically identify and describe guidelines for the care of neurologically deceased donors and to evaluate their methodological quality, with the aim of informing and supporting the new Canadian guidelines for the management of organ donors.

METHODOLOGY

Following a systematic search, we included any document endorsed by an organ donation organization, a professional society, or a government, that aims to direct the medical management of adult, neurologically deceased, multi-organ donors. We extracted recommendations pertaining to six domains: the autonomic storm, hemodynamic instability, hormone supplementation, ventilation, blood product transfusions, and general intensive care unit (ICU) care. Methodological quality of the guidelines was assessed by the validated AGREE-II tool.

MAIN FINDINGS

This review includes 27 clinical practice guidelines representing 26 countries published between 1993 and 2019. Using the AGREE-II validated tool for the evaluation of guidelines' quality, documents generally scored well on their scope and clarity of presentation. Nevertheless, quality was limited in terms of the scientific rigor of guideline development. Recommendations varied substantially across the domains of managing the autonomic storm, subsequent management of hemodynamic instability, hormone therapy, mechanical ventilation, blood product transfusion, and general ICU care. We found consistent recommendations for low tidal volume ventilation subsequent to the publication of a landmark clinical trial.

CONCLUSION

Highly inconsistent recommendations for deceased donor care summarized in this review likely reflect the relatively slow emergence of high-quality clinical research in this field, as well as a late uptake of recent validated guideline methodology. Even in this context of few randomized-controlled trials, our group supported the need for new Canadian guidelines for the management of organ donors that follow rigorous recognized methodology and grading of the evidence.

TRIAL REGISTRATION

PROSPERO (CRD42018084012); registered 25 February 2016.

Patient-centered care coordination, education and counseling of patients treated with oral anticancer drugs: An importance-performance analysis

PURPOSE

To analyse the importance and performance of key elements in patient-centered care coordination, education and counseling of patients treated with oral anticancer drugs.

METHOD

In four Belgian non-academic hospitals, the importance and performance of a set of 82 key elements was cross-sectionally evaluated by primary and secondary healthcare professionals and by patients. These key elements were divided in 6 themes: coordination of care, style and content of patient contacts, medication counseling at treatment initiation, follow-up of treatment, psychosocial support, and involvement of family and friends. Participants were asked to indicate for each key element if it was implemented in the current care process for patients on oral anticancer drugs ('yes', 'no', 'I don't know') and if they considered it important that the component was implemented or would be in the future ('yes' or 'no'). Three levels of performance were defined, based on the number of participants who had answered 'yes' or 'no': 'systematically performed' (≥90% of participants), 'not systematically performed' (≥75% and <90%) and 'not performed' (<75%). Importance-rates were based on the number of 'yes' or 'no'.

RESULTS

In total, 85 participants evaluated the key elements. More than half of key elements, 13/82 (15.9%) and 35/82 (42.6%) respectively, were considered as 'not' or 'not systematically performed'. The majority of these elements concerned coordination of care, medication counseling at treatment initiation and follow-up of treatment. Especially key elements on involving primary care and on discussing adherence had low performance rates. Nearly all key elements were assigned an importance score of ≥90%.

CONCLUSIONS

Performance of key elements of patient-centered care coordination, education and counseling of patients treated with oral anticancer drugs proved moderate. Our findings suggest that strategies are needed to prioritize and operationalize key elements to coordinate transmural care and to provide effective education and counseling.

A Canadian survey of critical care physicians' hemodynamic management of deceased organ donors

PURPOSE

We sought to characterize Canadian physicians' perspectives and stated practices regarding their hemodynamic care of deceased organ donors.

METHODS

We designed a 24-item electronic survey that was independently pretested for relevance, clarity, and intra-rater reliability by ten critical care clinicians. With the help of provincial organ donation organizations (ODO), we identified intensive care units (ICUs) with a high volume of adult deceased donors (defined by the management of five or more donors per year for two consecutive years). Medical directors of these high-volume ICUs helped identify ICU physicians to whom our survey was emailed.

RESULTS

Of the 448 ICU physicians from 37 centres in nine provinces that were emailed, 184/448 (41.1%) responded to one or more survey questions. Respondents identified specialist nurses from ODOs as their primary source of guidance in donor care (107/165; 60%). They typically diagnosed an autonomic storm according to a rise in blood pressure (159/165; 96.4%) and/or heart rate (135/165; 81.8%); nevertheless, their stated management varied substantially. After termination of the autonomic storm, preferred first-line vasopressors were norepinephrine (93/164; 56.7%) and vasopressin (68/164; 41.5%). Twenty-one respondents (21/162; 13.0%) reported that they never administer inotropes to donors. Corticosteroid and thyroid hormone prescriptions for all donors was reported by 62/161 (37.6%) and 50/161 (31.1%) respondents, respectively. Respondents perceived an influence from ODO nurses or transplant physicians when prescribing corticosteroids (77/161; 47.8%) and/or thyroid hormones (33/161; 20.5%) CONCLUSION: We observed important variability in self-perceived practices of ICU physicians in the hemodynamic management of deceased donors, particularly in the treatment of the autonomic storm, in the prescription of hormone therapy, and in the administration of inotropes.

Management of donation after brain death (DBD) in the ICU: the potential donor is identified, what's next?

The success of any donation process requires that potential brain-dead donors (PBDD) are detected and referred early to professionals responsible for their evaluation and conversion to actual donors. The intensivist plays a crucial role in organ donation. However, identification and referral of PBDDs may be suboptimal in the critical care environment. Factors influencing lower rates of detection and referral include the lack of specific training and the need to provide concomitant urgent care to other critically ill patients. Excellent communication between the ICU staff and the procurement organization is necessary to ensure the optimization of both the number and quality of organs transplanted. The organ donation process has been improved over the last two decades with the involvement and commitment of many healthcare professionals. Clinical protocols have been developed and implemented to better organize the multidisciplinary approach to organ donation. In this manuscript, we aim to highlight the main steps of organ donation, taking into account the following: early identification and evaluation of the PBDD with the use of checklists; donor management, including clinical maintenance of the PBDD with high-quality intensive care to prevent graft failure in recipients and strategies for optimizing donated organs by simplified care standards, clinical guidelines and alert tools; the key role of the intensivist in the donation process with the interaction between ICU professionals and transplant coordinators, nurse protocol managers, and communication skills training; and a final remark on the importance of the development of research with further insight into brain death pathophysiology and reversible organ damage.