In-house Coordinators Research Articles

A framework for cross-cultural development and implementation of complex interventions to improve palliative care in nursing homes: the PACE steps to success programme

BackgroundThe PACE Steps to Success programme is a complex educational and development intervention to improve palliative care in nursing homes. Little research has investigated processes in the cross-cultural adaptation and implementation of interventions in palliative care across countries, taking account of differences in health and social care systems, legal and regulatory policies, and cultural norms. This paper describes a framework for the cross-cultural development and support necessary to implement such an intervention, taking the PACE Steps to Success programme as an exemplar.MethodsThe PACE Steps to Success programme was implemented as part of the PACE cluster randomised control trial in seven European countries. A three stage approach was used, a) preparation of resources; b) training in the intervention using a train-the-trainers model; and c) cascading support throughout the implementation. All stages were underpinned by cross-cultural adaptation, including recognising legal and cultural norms, sensitivities and languages. This paper draws upon collated evidence from minutes of international meetings, evaluations of training delivered, interviews with those delivering the intervention in nursing homes and providing and/or receiving support.ResultsSeventy eight nursing homes participated in the trial, with half randomized to receive the intervention, 3638 nurses/care assistants were identified at baseline. In each country, 1–3 trainers were selected (total n = 16) to deliver the intervention. A framework was used to guide the cross-cultural adaptation and implementation. Adaptation of three English training resources for different groups of staff consisted of simplification of content, identification of validated implementation tools, a review in 2 nursing homes in each country, and translation into local languages. The same training was provided to all country trainers who cascaded it into intervention nursing homes in local languages, and facilitated it via in-house PACE coordinators. Support was cascaded from country trainers to staff implementing the intervention.ConclusionsThere is little guidance on how to adapt complex interventions developed in one country and language to international contexts. This framework for cross-cultural adaptation and implementation of a complex educational and development intervention may be useful to others seeking to transfer quality improvement initiatives in other contexts.

Project of Cornea Donation in Rio de Janeiro: Analysis of the Implementation of an Organization Innovation Practice

BackgroundFor many cornea disorders, transplantation can be the treatment of first choice. In Brazil, there is a disparity in the number of transplants between regions due to the lack of an oriented system for cornea procurement.The aim of this study was to analyze the implementation of a system exclusively oriented toward the improvement of cornea recovery in the Rio de Janeiro State Organ Procurement Organization (OPO) area. With this system, all cornea donation activities were coordinated by the OPO after telephone referrals following asystolic death. From the perspective of health care innovation, we will discuss the role of the main participants and their interactions following the implementation phase. MethodsOne hospital was chosen to host the project following the first 2 years of the implementation of the State Cornea Donation System. We retrospectively analyzed all deaths between January 1 and December 31, 2016, using the hospital death records and the OPO referrals record. The strategic plan, documents, and interviews were carried out for the analysis of the implementation of this innovation in our region. ResultsOf 1720 deaths in 2016, 1093 (63.5%) were referred to the OPO following asystolic death for assessment and screening, but 819 of these potential tissue donors (PTDs) were not eligible for donation due to medical contraindications. The remaining 274 (25.1%) fulfilled the PTD criteria. Less than half of the families (n = 128) of these PTDs could be contacted requesting donation, but 50% consented. Finally, corneas were procured from 58 patients. The interactions between in-house coordinators and top managers were mandatory for the success of program implementation. ConclusionFor the first time in our country, cornea recovery took place following asystolic death with OPO coordination at a central level. The PTD rate could be estimated, and an analysis of the role of stakeholders could be made for the implementation phase of this innovation in our system.

当院におけるDonor Action Programにおける家族担当Coordinatorの役割—最期を選択すること—

当院におけるDonor Action Programにおける家族担当Coordinatorの役割—最期を選択すること—

当院Donor Action Programにおける多職種院内コーディネーターチームの有用性の検討

当院Donor Action Programにおける多職種院内コーディネーターチームの有用性の検討

Impact of Introducing Full-time In-house Coordinators on Referral and Organ Donation Rates in Rio de Janeiro Public Hospitals: A Health Care Innovation Practice

Establishing an organization to promote organ donation and a good organ procurement team assure quality and improve performance on organ donation rates. Brazil's organ procurement structure is based on 2 models disseminated worldwide: the "Spanish model," based on in-house coordinators, and the "American organ procurement organization (OPO) model," with extra-hospital coordinators. In 2006, Brazil's Federal Government had formally introduced the in-house coordination model for every hospital equipped with a mechanical ventilator bed. In January 2012, the Rio de Janeiro State OPO, Programa Estadual de Transplantes, introduced an innovation in the organization of the in-house coordination model in 4 selected public hospitals with high organ donation potential. It consisted in launching full-time in-house coordination teams, with≥1 physician and 2 nurses per hospital fully dedicated to organ procurement. The objectives were to observe the impact of this innovation in referral and organ donor conversion rates and to analyze the importance of middle managers in health care innovation implementation. Comparing the year before implementation (2011) and the year of 2014 showed that this innovation led to an overall increase in referrals-from 131 to 305 per year (+132%) and conversion rates-from 20% to 42% per year-resulting in an increase in number of donors from 26 to 128 per year (+390%). Despite wide variations among hospitals in the outcomes, our results seem very encouraging and express a positive impact of this model, suggesting that dissemination to other hospitals may increase the number of donors and transplants in our region.

Success of Another Hispanic Donation Model: The Puerto Rico Experience

Introduction: The Spanish model for increasing organ donation has proven to be effective, based on the involvement of trained health care personnel in the care of potential donors and their families early in the process. This model has been applied in other countries also. Donation through an OPO was started in Puerto Rico in 1994 by LifeLink Foundation. Donors per million (dpm) have increased from an average of 3 (1994-7) to 28 (2007-11). Aim: To identify factors that have resulted in the significant increase in organ donors. Methods: Review of strategies, specific measures, changes implemented and significant events as they correlate with the number of donors per study period. Five time periods were identified according to the increment in number of donors. Results: For the initial period of 1994-97, aggressive public education, OPO-hospital contracts, recruitment of local executive director, and agreement with Medical Examiner were the main factors, resulting in average of 3 dpm. At this time, only kidney transplant was done in the island. From 1998-2000, dpm grew to 10.2. In this period, support from the federal and state governments, emphasis on brain death declaration, huge media exposure and a new heart transplant program were crucial. For 2001-3, 16.9 dpm were achieved. Staff growth, training of local kidney recovery surgeons, and endorsement by the Health Department were instrumental. From 2004-6, dpm rose to 22.5. Internal restructuring, uniform brain death protocol adopted by hospitals, identification and development of high donor potential hospitals, “Zero denial by ME” policy, training of local liver recovery surgeon, implementation of collaborative project with clinical triggers and management protocols, recruitment of critical care specialists for donor management, fulltime in-house public affairs specialist and active volunteer program were salient actions. The most recent growth to 28 dpm occurred from 2007-11. Measures included designated requestor, in-house coordinator, hospital standard support orders, Donor Advisory Committees, first responders, first kidney-pancreas transplant and implementation of electronic Donor Registry. Through out, a continued emphasis on physician education, brain death declaration and culturally sensitive public awareness campaign have been sustained. Conclusions: Creating a culturally sensitive process that includes highly trained DRs, focused education efforts, appealing public campaigns, addition of in-house coordinators, and development of local transplant centers have contributed to the increase in organ donors in spite of limited health care infrastructure and resources. Our experience supports the implementation of the Spanish approach of organizational strategies to increasing organ donation.

Success of Another Hispanic Donation Model: The Puerto Rico Experience

Introduction: The Spanish model for increasing organ donation has proven to be effective, based on the involvement of trained health care personnel in the care of potential donors and their families early in the process. This model has been applied in other countries also. Donation through an OPO was started in Puerto Rico in 1994 by LifeLink Foundation. Donors per million (dpm) have increased from an average of 3 (1994-7) to 28 (2007-11). Aim: To identify factors that have resulted in the significant increase in organ donors. Methods: Review of strategies, specific measures, changes implemented and significant events as they correlate with the number of donors per study period. Five time periods were identified according to the increment in number of donors. Results: For the initial period of 1994-97, aggressive public education, OPO-hospital contracts, recruitment of local executive director, and agreement with Medical Examiner were the main factors, resulting in average of 3 dpm. At this time, only kidney transplant was done in the island. From 1998-2000, dpm grew to 10.2. In this period, support from the federal and state governments, emphasis on brain death declaration, huge media exposure and a new heart transplant program were crucial. For 2001-3, 16.9 dpm were achieved. Staff growth, training of local kidney recovery surgeons, and endorsement by the Health Department were instrumental. From 2004-6, dpm rose to 22.5. Internal restructuring, uniform brain death protocol adopted by hospitals, identification and development of high donor potential hospitals, “Zero denial by ME” policy, training of local liver recovery surgeon, implementation of collaborative project with clinical triggers and management protocols, recruitment of critical care specialists for donor management, fulltime in-house public affairs specialist and active volunteer program were salient actions. The most recent growth to 28 dpm occurred from 2007-11. Measures included designated requestor, in-house coordinator, hospital standard support orders, Donor Advisory Committees, first responders, first kidney-pancreas transplant and implementation of electronic Donor Registry. Through out, a continued emphasis on physician education, brain death declaration and culturally sensitive public awareness campaign have been sustained. Conclusions: Creating a culturally sensitive process that includes highly trained DRs, focused education efforts, appealing public campaigns, addition of in-house coordinators, and development of local transplant centers have contributed to the increase in organ donors in spite of limited health care infrastructure and resources. Our experience supports the implementation of the Spanish approach of organizational strategies to increasing organ donation.

Nudge, Nudge or Shove, Shove—The Right Way for Nudges to Increase the Supply of Donated Cadaver Organs

Richard Thaler and Cass Sunstein (2008) contend that mandated choice is the most practical nudge for increasing organ donation. We argue that they are wrong, and their mistake results from failing to appreciate how perceptions of meaning can influence people's responses to nudges. We favor a policy of default to donation that is subject to immediate family veto power, includes options for people to opt out (and be educated on how to do so), and emphasizes the role of organ procurement organizations and in-house transplant donation coordinators creating better environments for increasing the supply of organs and tissues obtained from cadavers. This policy will provide better opportunities for offering nudges in contexts where in-house coordinators work with families. We conclude by arguing that nudges can be introduced ethically and effectively into these contexts only if nudge designers collaborate with in-house coordinators and stakeholders.

In-House Coordinator Programs Improve Conversion Rates for Organ Donation

The organ supply shortage continues to be a public health care crisis, with nearly 20 people dying each day awaiting transplantation. Inability to obtain consent remains one of the major obstacles to converting potential donors into organ donors. We hypothesize that the presence of in-house coordinators (IHCs) from organ procurement organizations (OPOs) will improve organ donor conversion rates. This retrospective review analyzed the effect of an IHC program on organ donation outcome. Referrals for possible organ donation from three IHC programs to regional organ procurement organizations were included. Data regarding organ donation demographics and outcomes were compared before (Pre-IHC) and after (Post-IHC) the establishment of an IHC program. The main outcome measures were conversion and family decline rates. The conversion rate was calculated as the number of actual donors divided by the number of eligible deaths and is represented as a percentage. The IHC functioned to assess for potential donors, ensure timely referrals, provide hospital staff education, assist with family consent and donor management, and provide family support. Post-IHC was associated with a significantly lower family decline rate (6% vs. 18%, p < 0.001), a significantly higher consent for research rate (8% vs. 0.4%, p < 0.001), and a significantly higher conversion rate (77% vs. 63%, p = 0.007) compared with Pre-IHC. In addition, a significant increase in referrals per day (0.35 vs. 0.27, p < 0.05) and organs transplanted per eligible death were noted Post-IHC. The presence of an IHC program significantly improves conversion rates for organ donation as well as organ yield. An IHC program should be considered as a viable option to bridge the gap between organ supply and organ demand.

Detection of Potential Organ Donors: 2-Year Analysis of Deaths at a German University Hospital

In 2006, inhouse coordinators were introduced in all hospitals with intensive care units in Baden-Württemberg to improve organ donation. At our university hospital with a neurosurgery and a transplantation unit, we analyzed whether brain death certification and donation requests were always initiated (if possible). We retrospectively reviewed all 1312 hospital deaths from 2006-2007 by studying medical records and consulting with physicians. The possibility of organ donation was questioned. Donation was requested among 68/702 deaths due to cerebral complications. A request was impossible in 8 cases. Consent for donation was obtained in 29 cases, and it was realized in 24 cases. In 14 cases of resuscitation from shock or cardiac failure, therapy was not continued because of questionable hemodynamic stability. In 17 cases admitted to peripheral wards and 19 to intensive care units death due to cerebral complications occurred within 48 hours, but medical records were not relevant for exclusion criteria for organ donation. The detection of donors was not acceptable. In patients without a prognosis after resuscitation, further hemodynamic stabilization was frequently omitted, because organ donation had not been considered. In cases of donation requests the refusal rate was high. We initiated specific training.

Improving Donation Outcomes: Hospital Development and the Rapid Assessment of Hospital Procurement Barriers in Donation

Deficiencies in the donation process continue to contribute to the shortage of organs available for transplant. Continuous quality improvement of hospitals' donation processes is needed to identify and correct the problems. To test the Rapid Assessment of Hospital Procurement Barriers in Donation (RAPiD), a direct observation technique with a focused ethnographic strategy, for assessing hospitals' donation processes and identifying areas in need of continuous quality improvement interventions. A pre-post assessment of hospitals' barriers to patient identification and referral, and family consent to donation. Seventeen hospitals within the catchment area of a Northeastern organ procurement organization were assessed by using the RAPiD method. Hospital administrators, health care providers, and staff (N = 537) were interviewed as part of the assessments. Interventions, including on-site training and education, and the use of in-house coordinators, were specifically tailored to each hospital's unique set of barriers to donation. The interventions were delivered to the hospitals in the form of recommendations. The participating organ procurement organization was responsible for implementation of the interventions. The RAPiD hospital evaluations revealed gaps in respondents' knowledge of organ donation, brain death, and referral criteria; a reluctance to declare brain death; and a rocky relationship between the hospitals and the organ procurement organization. As a result of the interventions, 9 hospitals' environments for organ donation improved, 7 showed no change, and 1 was worse.

Improving donation outcomes: hospital development and the Rapid Assessment of Hospital Procurement Barriers in Donation

Deficiencies in the donation process continue to contribute to the shortage of organs available for transplant. Continuous quality improvement of hospitals' donation processes is needed to identify and correct the problems. To test the Rapid Assessment of Hospital Procurement Barriers in Donation (RAPiD), a direct observation technique with a focused ethnographic strategy, for assessing hospitals' donation processes and identifying areas in need of continuous quality improvement interventions. A pre-post assessment of hospitals' barriers to patient identification and referral, and family consent to donation. Seventeen hospitals within the catchment area of a Northeastern organ procurement organization were assessed by using the RAPiD method. Hospital administrators, health care providers, and staff (N = 537) were interviewed as part of the assessments. Interventions, including on-site training and education, and the use of in-house coordinators, were specifically tailored to each hospital's unique set of barriers to donation. The interventions were delivered to the hospitals in the form of recommendations. The participating organ procurement organization was responsible for implementation of the interventions. The RAPiD hospital evaluations revealed gaps in respondents' knowledge of organ donation, brain death, and referral criteria; a reluctance to declare brain death; and a rocky relationship between the hospitals and the organ procurement organization. As a result of the interventions, 9 hospitals' environments for organ donation improved, 7 showed no change, and 1 was worse.

Improving Consent Rates for Organ Donation: The Effect of an Inhouse Coordinator Program

The inability to obtain consent remains one of the major obstacles to organ donation. The presence of in-house coordinators (IHCs) from organ procurement organizations (OPOs) might substantially improve donation rates. To review the preliminary results of the effect of the presence of an IHC on organ donation rates at our center. This is a retrospective analysis of patients referred to the regional OPO for possible organ donation. An IHC program was started at our hospital in late 2001. Data regarding organ donation demographics and family consent rates were compared before (Pre-IHC, 1998-2001) and after (Post-IHC, 2002-2005) the institution of an IHC program. The conversion rate was calculated as the number of actual donors divided by the number of potential donors and is represented as a percentage. The function of the IHC was to assist in donor surveillance, ensure timely referral, provide hospital staff education, assist with family consent and donor management, and provide family support. There were a total of 495 potential donors and 195 actual donors during the 8-year time period. Post-IHC was associated with a significantly higher consent rate (52% vs. 35%, p < 0.01), a significantly higher conversion rate (50% vs. 34%, p < 0.01), and a 17% increase in organs donated compared with Pre-IHC. The presence of an IHC program significantly improves consent and conversion rates for organ donation. An IHC program should be considered as a viable option to bridge the gap between organ supply and organ demand.

Increasing Organ Recovery from Level I Trauma Centers: The In-House Coordinator Intervention

Daily presence of organ procurement organization staff in level I trauma centers combined with early family contact and interaction can increase donation rates. A successful in-house coordinator program already in place at 2 level I trauma centers in Houston was replicated in 6 other level I trauma centers in New York City, Los Angeles, and Seattle. Organ procurement organization staff were placed inside the 8 trauma centers to provide early family support in potential donor situations and day-to-day donation system management. Comparison data were obtained on 83 level I trauma centers nationally. Data from 1999 to 2000 were compared with data from 2001 to 2002. Despite demographic differences, the 8 centers with in-house coordinators had higher consent rates (60% vs 53%) and conversion rates (55% vs 45%) than centers without them. Conversion of potential to actual donors was 22% higher in centers with in-house coordinators than in centers without them. Donation rates were affected by donor age, ethnicity, previous family discussion of donation, the family's initial reaction to the request (favorable, unfavorable, undecided), amount of time family spent with the in-house coordinator, presence of the in-house coordinator during explanation of brain death, whether the request was made at the same time as the brain-death explanation, and, in cases where donation was mentioned to the family before the formal request, who first mentioned donation to the family. In-house coordinators improve the donation process by interacting with families and staff earlier and more often during potential organ donations and improving donation systems through closer relationships with hospital staff.

Increasing organ recovery from level I trauma centers: the in-house coordinator intervention

Daily presence of organ procurement organization staff in level I trauma centers combined with early family contact and interaction can increase donation rates. A successful in-house coordinator program already in place at 2 level I trauma centers in Houston was replicated in 6 other level I trauma centers in New York City, Los Angeles, and Seattle. Organ procurement organization staff were placed inside the 8 trauma centers to provide early family support in potential donor situations and day-to-day donation system management. Comparison data were obtained on 83 level I trauma centers nationally. Data from 1999 to 2000 were compared with data from 2001 to 2002. Despite demographic differences, the 8 centers with in-house coordinators had higher consent rates (60% vs 53%) and conversion rates (55% vs 45%) than centers without them. Conversion of potential to actual donors was 22% higher in centers with in-house coordinators than in centers without them. Donation rates were affected by donor age, ethnicity, previous family discussion of donation, the family's initial reaction to the request (favorable, unfavorable, undecided), amount of time family spent with the in-house coordinator, presence of the in-house coordinator during explanation of brain death, whether the request was made at the same time as the brain-death explanation, and, in cases where donation was mentioned to the family before the formal request, who first mentioned donation to the family. In-house coordinators improve the donation process by interacting with families and staff earlier and more often during potential organ donations and improving donation systems through closer relationships with hospital staff.

Organ donation: what can we learn from North America?

The aim of this qualitative case study was to investigate how organ donation is promoted and managed in North America aimed specifically at patients and relatives. A 4-week study to Boston and Baltimore in America was undertaken to observe and learn how organ donation is promoted and managed within a critical care environment. The study tour was undertaken specifically to examine the policy and procedures that enhance the procurement of organ donation in specific centres in the USA. The study tour wanted to examine and gain a better understanding of the issues, policies and procedures used by these centres when seeking permission for organ donation. Data were collected by a variety of methods involving observation, unstructured informal interviews, examinations of policies and procedures and a daily diary was maintained. A thematic analysis method was used to analyse the qualitative data collected. Four areas were identified as potential areas for learning. Approaching relatives of potential donors for consent, at a time of intense emotional crisis, is a challenge that involves all nurses working in critical areas. Nurses are identified as a key component in the process of organ donation; research highlights that approaching relatives can be problematic and stressful for nursing staff. The British government should consider required request legislation that ensures all hospitals refer potential donors to the Regional Transplant Center. In-house coordinators could be appointed and protocols developed for referrals of potential donors. It is also suggested that the approach for consent is decoupled and designated requesters approach relatives.

Location of in-house organ procurement organization staff in level I trauma centers increases conversion of potential donors to actual donors.

Of 5810 acute care hospitals in the United States, only 3.9% (231) are Level 1 Trauma Centers (L1TCs). L1TCs have a significant number of potential organ donors (PODs). Placement of Organ Procurement Organization (OPO) staff, In House Coordinators (IHCs), directly within the L1TC to increase the number of families who consent to donate and to provide system management for the trauma center's donation program, was evaluated. Four OPO staff, IHCs, were placed in offices inside two L1TCs in Houston, Texas. The IHCs were responsible for development of a donation system, donor surveillance, management, and most importantly, family support. Calendar year 2000 data on conversion of PODs to actual donors were compared between the L1TCs with IHCs (IHC-L1TC) (n=2) and trauma centers without IHCs (n=4) within the OPO's service area. IHC-L1TCs converted 44% more of the PODs to actual donors. Furthermore, the IHC-L1TCs were compared with 85 L1TCs (37% of U.S. L1TCs) without IHCs. IHC-L1TCs had a 28% greater donor consent rate and a 48% greater conversion rate of PODs to actual donors than the national L1TCs. L1TC status is the America College of Surgeons' highest level of verification for trauma care. To be certified as a L1TC, hospitals must meet strict criteria in both services and patient care. The donation process is often profoundly affected by the burden of demands made on the resources of these institutions and from divergent responsibilities between specialty services within the facility. Dedicated IHCs (OPO staff) are needed to provide early family intervention and to orchestrate the donation process to maximize organ recovery.

Texas Non—Donor-Hospital Project: A Program to Increase Organ Donation in Community and Rural Hospitals

Identifying and recovering donors from community and rural hospitals present a challenge to organ procurement organizations. A study of non-donor hospitals in the United States was undertaken at Johns Hopkins University, which identified 31 hospitals (in one service area) with the facilities to accommodate organ donation, though an organ donor had not been produced in 3 years. The purpose of this study was to determine whether donors could be produced from these hospitals. A large, geographically dispersed OPO initiated a program consisting of (1) in-house coordinators, and (2) routine notification of all hospital deaths. Following implementation of this program, organ donation increased 387% among the targeted 25 hospitals. The number of hospitals producing at least 1 organ donor increased 133%. The number of organs recovered in the project increased 449%. In-house coordinators, by identifying potential donors and facilitating an organ donor awareness program, can increase the number of organ donors in hospitals with low, but real, donor potential.

Texas non-donor-hospital project: a program to increase organ donation in community and rural hospitals.

Identifying and recovering donors from community and rural hospitals present a challenge to organ procurement organizations. A study of non-donor hospitals in the United States was undertaken at Johns Hopkins University, which identified 31 hospitals (in one service area) with the facilities to accommodate organ donation, though an organ donor had not been produced in 3 years. The purpose of this study was to determine whether donors could be produced from these hospitals. A large, geographically dispersed OPO initiated a program consisting of (1) in-house coordinators, and (2) routine notification of all hospital deaths. Following implementation of this program, organ donation increased 387% among the targeted 25 hospitals. The number of hospitals producing at least 1 organ donor increased 133%. The number of organs recovered in the project increased 449%. In-house coordinators, by identifying potential donors and facilitating an organ donor awareness program, can increase the number of organ donors in hospitals with low, but real, donor potential.

An In-House Coordinator Program to Increase Organ Donation in Public Trauma Hospitals

A 4-year retrospective study was conducted regarding the donor potential, consent rates, and organ recovery at a large 500-bed public trauma hospital. An independent organ procurement organization hired two in-house coordinators, one white and one black, to work exclusively in the hospital. The duties of the in-house coordinators included the following: working with nurses, physicians, and residents to identify donors; closely managing and coordinating the consent process; and assisting organ procurement coordinators in donor management. Following the program's implementation and the use of race-specific requesters, a 64% increase in consent rate resulted along with an overall increase of 94% in the number of organ donors. The consent rate of blacks increased 115%, whereas the number of black organ donors increased 154%. The Hispanic consent rate increased 48% with a corresponding increase of 83% in the number of Hispanic organ donors. In addition, the white consent rate increased from 55% (the 3-year average from 1993 to 1995) to 75% in 1996, resulting in a 36% increase following the implementation of the program. The investment of dedicated race-sensitive personnel in large urban county trauma facilities can result in a significant increase in donor conversion rates.