Supporting Cancer Survivors Following Treatment for Non-Hodgkin's and Hodgkin's Lymphoma: A Pilot Study Assessing the Feasibility and Process Outcomes of a Nurse-Led Intervention.

OBJECTIVE: Lymphoma is the sixth most common cancer in Australia and comprises 2.8% of worldwide cancer diagnoses. Research targeting development and evaluation of post-treatment care for debilitating complications resulting from the disease and its treatment is limited. This study aimed to assess the feasibility and acceptability of a nurse-led survivorship intervention, post-treatment in Hodgkin's and non-Hodgkin's lymphoma survivors. METHODS: A single-center, prospective, 3-arm, pilot, randomized controlled, parallel-group trial was used. People with lymphoma were recruited and randomized to the intervention (ENGAGE), education booklet only, or usual care arm. Participants receiving ENGAGE received an educational booklet and were offered 3 consultations (via various modes) with a cancer nurse to develop a survivorship care plan and healthcare goals. Participant distress and intervention acceptability was measured at baseline and 12-wk. Acceptability was measured via a satisfaction survey using a 11-point scale. Feasibility was measured using participation, retention rates, and process outcomes. Data were analyzed using descriptive statistics. RESULTS: Thirty-four participants with HL and NHL were recruited to the study (11 = intervention, 11 = information only, 12 = usual care). Twenty-seven participants (79%) completed all time points from baseline to 12 wk. Seven (88%) of the 8 participants receiving ENGAGE completed all consultations using various modes to communicate with the nurse (videoconference 14/23, 61%; phone 5/23, 22%; face-to-face 4/23, 17%). Participants who completed the intervention were highly satisfied with ENGAGE. CONCLUSION: The ENGAGE intervention is feasible and highly acceptable for lymphoma survivors. These findings will inform a larger trial assessing effectiveness and cost effectiveness of ENGAGE.

Clinical indicators of acute deterioration in persons who reside in residential aged care facilities: A rapid review.

PURPOSE: To identify the clinical indicators of acute deterioration in residents and the factors that influence residential aged care facility staff's identification of these. DESIGN: Rapid review and narrative synthesis. METHODS: The WHO and Cochrane Rapid Review Methods Group recommendations guided the review processes. CINAHL, Medline, PubMed, and the Cochrane Library were searched from 2000 to January 2022. Data related to clinical indicators of deterioration were categorized using the Airway, Breathing, Circulation, Disability, Exposure assessment framework, and factors influencing detection were grouped as consumer (resident and family), aged care workforce, and organization factors. RESULTS: Twenty publications were included of which 14 informed clinical indicators; nine highlighted factors that influence staff's identification of these and three informed both. Included article were collectively below moderate quality. Most clinical indicators were grouped into the 'Disability' category with altered level of consciousness, behavior, and pain identified most frequently. Few studies reported more traditional indicators of deterioration used in the general population - changes in vital signs. The most common factors influencing the detection of acute deterioration were organizational and workforce-related including resource, knowledge, and confidence deficits. CONCLUSION: Findings suggest subtle changes in resident's health status, rather than focusing primarily on physiologic parameters used in early warning tools for acute care settings, should be recognized and considered in the design of early warning tools for residential aged care facilities. CLINICAL RELEVANCE: Early warning tools sensitive to the unique needs of residents and support for aged care facility staff are recommended to improve the capacity of aged care facility care staff to identify and manage acute deterioration early to avoid hospitalization.

Non-Pharmacological Self-Management Strategies for Chemotherapy-Induced Peripheral Neuropathy in People with Advanced Cancer: A Systematic Review and Meta-Analysis.

Non-pharmacological self-management interventions for chemotherapy-induced peripheral neurotherapy (CIPN) are of clinical interest; however, no systematic review has synthesized the evidence for their use in people with advanced cancer. Five databases were searched from inception to February 2022 for randomized controlled trials assessing the effect of non-pharmacological self-management interventions in people with advanced cancer on the incidence and severity of CIPN symptoms and related outcomes compared to any control condition. Data were pooled with meta-analysis. Quality of evidence was appraised using the Revised Cochrane Risk of Bias Tool for Randomized Trials (RoB2), with data synthesized narratively. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was applied to assess the certainty of the evidence. Thirteen studies were included, which had a high (69%) or unclear (31%) risk of bias. Greatest confidence was found for physical exercise decreasing CIPN severity (SMD: -0.89, 95% CI: -1.37 to -0.41; p = 0.0003; I2 = 0%; n = 2 studies, n = 76 participants; GRADE level: moderate) and increasing physical function (SMD: 0.51, 95% CI: 0.02 to 1.00; p = 0.04; I2 = 42%; n = 3 studies, n = 120; GRADE level: moderate). One study per intervention provided preliminary evidence for the positive effects of glutamine supplementation, an Omega-3 PUFA-enriched drink, and education for symptom self-management via a mobile phone game on CIPN symptoms and related outcomes (GRADE: very low). No serious adverse events were reported. The strongest evidence with the most certainty was found for physical exercise as a safe and viable adjuvant to chemotherapy treatment for the prevention and management of CIPN and related physical function in people with advanced cancer. However, the confidence in the evidence to inform conclusions was mostly very low to moderate. Future well-powered and appropriately designed interventions for clinical trials using validated outcome measures and clearly defined populations and strategies are warranted.

Cannula and circuit management in peripheral extracorporeal membrane oxygenation: An international survey of 45 countries.

Effective and safe practices during extracorporeal membrane oxygenation (ECMO) including infection precautions and securement of lines (cannulas and circuits) are critical to prevent life-threatening patient complications, yet little is known about the practices of bedside clinicians and data to support best practice is lacking. Therefore, the aim of this study was to identify and describe common line-related practices for patients supported by peripheral ECMO worldwide and to highlight any gaps for further investigation. An electronic survey was conducted to examine common line practices for patients managed on peripheral ECMO. Responses were obtained from 45 countries with the majority from the United States (n = 181) and United Kingdom (n = 32). Standardised infection precautions including hand hygiene, maximal barrier precautions and skin antisepsis were commonplace for cannulation. The most common antisepsis strategies included alcohol-based chlorhexidine gluconate (CHG) for cannula insertion (53%) and maintenance (54%), isopropyl alcohol on circuit access ports (39%), and CHG-impregnated dressings to cover insertion sites (36%). Adverse patient events due to line malposition or dislodgement were reported by 34% of respondents with most attributable to ineffective securement. Centres 'always' suturing peripheral cannula sites were more likely to experience a cannula adverse event than centres that 'never' sutured (35% [95% CI 30, 41] vs 0% [95% CI 0, 28]; Chi-square 4.40; p = 0.04) but this did not meet the a priori significance level of <0.01. An evidence-based guideline would be beneficial to improve ECMO line management according to 78% of respondents. Evidence gaps were identified for antiseptic agents, dressing products and regimens, securement methods, and needleless valves. Future research addressing these areas may provide opportunities for consensus guideline development and practice improvement.

Do nurse navigators bring about fewer patient hospitalisations?

PURPOSE: Nurse navigators (NNs) coordinate patient care, improve care quality and potentially reduce healthcare resource use. The purpose of this paper is to undertake an evaluation of hospitalisation outcomes in a new NN programme in Queensland, Australia. DESIGN/METHODOLOGY/APPROACH: A matched case-control study was performed. Patients under the care of the NNs were randomly selected ( n=100) and were matched to historical ( n=300) and concurrent ( n=300) comparison groups. The key outcomes of interest were the number and types of hospitalisations, length of hospital stay and number of intensive care unit days. Generalised linear and two-part models were used to determine significant differences in resources across groups. FINDINGS: The control and NN groups were well matched on socio-economic characteristics, however, groups differed by major disease type and number/type of comorbidities. NN patients had high healthcare needs with 53 per cent having two comorbidities. In adjusted analyses, compared with the control groups, NN patients showed higher proportions of preventable hospitalisations over 12 months, similar days in intensive care and a smaller proportion had overnight stays in hospital. However, the NN patients had significantly more hospitalisations (mean: 6.0 for NN cases, 3.4 for historical group and 3.2 for concurrent group); and emergency visits. RESEARCH LIMITATIONS/IMPLICATIONS: As many factors will affect hospitalisation rates beyond whether patients receive NN care, further research and longer follow-up is required. ORIGINALITY/VALUE: A matched case-control study provides a reasonable but insufficient design to compare the NN and non-NN exposed patient outcomes.

Interruptions During Senior Nurse Handover in the Intensive Care Unit: A Quality Improvement Study.

BACKGROUND: Interruptions during handover may compromise continuity of care and patient safety. LOCAL PROBLEM: Interruptions occur frequently during handovers in the intensive care unit. METHODS: A quality improvement study was undertaken to improve nursing team leader handover processes. The frequency, source, and reason interruptions occurred were recorded before and after a handover intervention. INTERVENTIONS: The intervention involved relocating handover from the desk to bedside and using a printed version of an evidence-based electronic minimum data set. These strategies were supported by education, champions, reminders, and audit and feedback. RESULTS: Forty handovers were audiotaped before, and 49 were observed 3 months following the intervention. Sixty-four interruptions occurred before and 52 after the intervention, but this difference was not statistically significant. Team leaders were frequently interrupted by nurses discussing personal or work-specific matters before and after the intervention. CONCLUSIONS: Further work is required to reduce interruptions that do not benefit patient care.

A comparison of the effects of manual hyperinflation and ventilator hyperinflation on restoring end-expiratory lung volume after endotracheal suctioning: A pilot physiologic study.

PURPOSE: Endotracheal suctioning (ES) of mechanically ventilated patients decreases end-expiratory lung volume (EELV). Manual hyperinflation (MHI) and ventilator hyperinflation (VHI) may restore EELV post-ES but it remains unknown which method is most effective. The primary aim was to compare the efficacy of MHI and VHI in restoring EELV post-ES. MATERIALS AND METHODS: ES was performed on mechanically ventilated intensive care patients, followed by MHI or VHI, in a randomised crossover design. The washout period between interventions was 1 h. End-expiratory lung impedance (EELI), measured by electrical impedance tomography, was recorded at baseline, during ES, during hyperinflation and 1, 5, 15 and 30 min post-hyperinflation. RESULTS: Nine participants were studied. ES decreased EELI by 1672z (95% CI, 1204 to 2140) from baseline. From baseline, MHI increased EELI by 1154z (95% CI, 977 to 1330) while VHI increased EELI by 769z (95% CI, 457 to 1080). Five minutes post-VHI, EELI remained 528z (95% CI, 4 to 1053) above baseline. Fifteen minutes post-MHI, EELI remained 351z (95% CI, 111 to 592) above baseline. At subsequent time-points, EELI returned to baseline. CONCLUSIONS: MHI and VHI effectively restore EELV above baseline post-ES and should be considered post suctioning.

Implementation of an Evidence-Based Practice Nursing Handover Tool in Intensive Care Using the Knowledge-to-Action Framework.

BACKGROUND: Miscommunication during handover has been linked to adverse patient events and is an international patient safety priority. Despite the development of handover resources, standardized handover tools for nursing team leaders (TLs) in intensive care are limited. AIMS: The study aim was to implement and evaluate an evidence-based electronic minimum data set for nursing TL shift-to-shift handover in the intensive care unit using the knowledge-to-action (KTA) framework. METHODS: This study was conducted in a 21-bed medical-surgical intensive care unit in Queensland, Australia. Senior registered nurses involved in TL handover were recruited. Three phases of the KTA framework (select, tailor, and implement interventions; monitor knowledge use; and evaluate outcomes) guided the implementation and evaluation process. A postimplementation practice audit and survey were carried out to determine nursing TL use and perceptions of the electronic minimum data set 3 months after implementation. Results are presented using descriptive statistics (median, IQR, frequency, and percentage). RESULTS: Overall (86%, n = 49), TLs' use of the electronic minimum data set for handover and communication regarding patient plan increased. Key content items, however, were absent from handovers and additional documentation was required alongside the minimum data set to conduct handover. Of the TLs surveyed (n = 35), those receiving handover perceived the electronic minimum data set more positively than TLs giving handover (n = 35). Benefits to using the electronic minimum data set included the patient content (48%), suitability for short-stay patients (16%), decreased time updating (12%), and printing the tool (12%). Almost half of the participants, however, found the minimum data set contained irrelevant information, reported difficulties navigating and locating relevant information, and pertinent information was missing. Suggestions for improvement focused on modifications to the electronic handover interface. LINKING EVIDENCE TO ACTION: Prior to developing and implementing electronic handover tools, adequate infrastructure is required to support knowledge translation and ensure clinician and organizational needs are met.

Developing a minimum dataset for nursing team leader handover in the intensive care unit: A focus group study.

BACKGROUND: Despite increasing demand for structured processes to guide clinical handover, nursing handover tools are limited in the intensive care unit. OBJECTIVES: The study aim was to identify key items to include in a minimum dataset for intensive care nursing team leader shift-to-shift handover. METHODS: This focus group study was conducted in a 21-bed medical/surgical intensive care unit in Australia. Senior registered nurses involved in team leader handovers were recruited. Focus groups were conducted using a nominal group technique to generate and prioritise minimum dataset items. Nurses were presented with content from previous team leader handovers and asked to select which content items to include in a minimum dataset. Participant responses were summarised as frequencies and percentages. RESULTS: Seventeen senior nurses participated in three focus groups. Participants agreed that ISBAR (Identify-Situation-Background-Assessment-Recommendations) was a useful tool to guide clinical handover. Items recommended to be included in the minimum dataset (≥65% agreement) included Identify (name, age, days in intensive care), Situation (diagnosis, surgical procedure), Background (significant event(s), management of significant event(s)) and Recommendations (patient plan for next shift, tasks to follow up for next shift). Overall, 30 of the 67 (45%) items in the Assessment category were considered important to include in the minimum dataset and focused on relevant observations and treatment within each body system. Other non-ISBAR items considered important to include related to the ICU (admissions to ICU, staffing/skill mix, theatre cases) and patients (infectious status, site of infection, end of life plan). Items were further categorised into those to include in all handovers and those to discuss only when relevant to the patient. CONCLUSIONS: The findings suggest a minimum dataset for intensive care nursing team leader shift-to-shift handover should contain items within ISBAR along with unit and patient specific information to maintain continuity of care and patient safety across shift changes.

Are pressure injuries related to skin failure in critically ill patients?

BACKGROUND: Pressure injuries contribute significantly to patient morbidity and healthcare costs. Critically ill patients are a high risk group for pressure injury development and may suffer from skin failure secondary to hypoperfusion. The aim of this study was to report hospital acquired pressure injury incidence in intensive care and non-intensive care patients; and assess the clinical characteristics and outcomes of ICU patients reported as having a hospital acquired pressure injury to better understand patient factors associated with their development in comparison to ward patients. METHODS: The setting for this study was a 630 bed, government funded, tertiary referral teaching hospital. A secondary data analysis was undertaken on all patients with a recorded PI on the hospital's critical incident reporting systems and admitted patient data collection between July 2006 to March 2015. RESULTS: There were a total of 5280 reports in 3860 patients; 726 reports were intensive care patients and 4554 were non-intensive care patients, with severe hospital acquired PI reported in 22 intensive care patients and 54 non-intensive care patients. Pressure injury incidence increased in intensive care patients and decreased in non-intensive care patients over the study period. There were statistically significant differences in the anatomical location of severe hospital acquired pressure injuries between these groups (p=0.008). CONCLUSION: Intensive care patients have greater than 10-fold higher hospital acquired pressure injury incidence rates compared to other hospitalised patients. The predisposition of critically ill patients leaves them susceptible to pressure injury development despite implementation of pressure injury prevention strategies. Skin failure appears to be a significant phenomenon in critically ill patients and is associated with the use of vasoactive agents and support systems such as extra corporeal membrane oxygenation and mechanical ventilation.

Barriers and facilitators to the implementation of an evidence-based electronic minimum dataset for nursing team leader handover: A descriptive survey.

INTRODUCTION: There is widespread use of clinical information systems in intensive care units however, the evidence to support electronic handover is limited. OBJECTIVES: The study aim was to assess the barriers and facilitators to use of an electronic minimum dataset for nursing team leader shift-to-shift handover in the intensive care unit prior to its implementation. METHODS: The study was conducted in a 21-bed medical/surgical intensive care unit, specialising in cardiothoracic surgery at a tertiary referral hospital, in Queensland, Australia. An established tool was modified to the intensive care nursing handover context and a survey of all 63 nursing team leaders was undertaken. Survey statements were rated using a 6-point Likert scale with selections from 'strongly disagree' to 'strongly agree', and open-ended questions. Descriptive statistics were used to summarise results. RESULTS AND DISCUSSION: A total of 39 team leaders responded to the survey (62%). Team leaders used general intensive care work unit guidelines to inform practice however they were less familiar with the intensive care handover work unit guideline. Barriers to minimum dataset uptake included: a tool that was not user friendly, time consuming and contained too much information. Facilitators to minimum dataset adoption included: a tool that was user friendly, saved time and contained relevant information. Identifying the complexities of a healthcare setting prior to the implementation of an intervention assists researchers and clinicians to integrate new knowledge into healthcare settings. CONCLUSION: Barriers and facilitators to knowledge use focused on usability, content and efficiency of the electronic minimum dataset and can be used to inform tailored strategies to optimise team leaders' adoption of a minimum dataset for handover.

Nasal high flow oxygen therapy in patients with COPD reduces respiratory rate and tissue carbon dioxide while increasing tidal and end-expiratory lung volumes: a randomised crossover trial.

UNLABELLED: Patients with COPD using long-term oxygen therapy (LTOT) over 15 h per day have improved outcomes. As inhalation of dry cold gas is detrimental to mucociliary clearance, humidified nasal high flow (NHF) oxygen may reduce frequency of exacerbations, while improving lung function and quality of life in this cohort. In this randomised crossover study, we assessed short-term physiological responses to NHF therapy in 30 males chronically treated with LTOT. LTOT (2-4 L/min) through nasal cannula was compared with NHF at 30 L/min from an AIRVO through an Optiflow nasal interface with entrained supplemental oxygen. Comparing NHF with LTOT: transcutaneous carbon dioxide (TcCO2) (43.3 vs 46.7 mm Hg, p<0.001), transcutaneous oxygen (TcO2) (97.1 vs 101.2 mm Hg, p=0.01), I:E ratio (0.75 vs 0.86, p=0.02) and respiratory rate (RR) (15.4 vs 19.2 bpm, p<0.001) were lower; and tidal volume (Vt) (0.50 vs 0.40, p=0.003) and end-expiratory lung volume (EELV) (174% vs 113%, p<0.001) were higher. EELV is expressed as relative change from baseline (%Δ). Subjective dyspnoea and interface comfort favoured LTOT. NHF decreased TcCO2, I:E ratio and RR, with a concurrent increase in EELV and Vt compared with LTOT. This demonstrates a potential mechanistic rationale behind the improved outcomes observed in long-term treatment with NHF in oxygen-dependent patients. TRIAL REGISTRATION NUMBER: ACTRN12613000028707.

Wrist acupressure for post-operative nausea and vomiting (WrAP): A pilot study.

Post-operative nausea and vomiting are undesirable complications following anaesthesia and surgery. It is thought that acupressure might prevent nausea and vomiting through an alteration in endorphins and serotonin levels. In this two-group, parallel, superiority, randomised control pilot trial we aimed to test pre-defined feasibility outcomes and provide preliminary evidence for the efficacy of PC 6 acupoint stimulation vs. placebo for reducing post-operative nausea and vomiting in cardiac surgery patients. Eighty patients were randomly assigned to either an intervention PC 6 acupoint stimulation via beaded intervention wristbands group (n=38) or placebo sham wristband group (n=42). The main outcome was assessment of pre-defined feasibility criteria with secondary outcomes for nausea, vomiting, rescue anti-emetic therapy, quality of recovery and adverse events. Findings suggest that a large placebo-controlled randomised controlled trial to test the efficacy of PC 6 stimulation on PONV in the post-cardiac surgery population is feasible and justified given the preliminary clinically significant reduction in vomiting in the intervention group in this pilot. The intervention was tolerated well by participants and if wrist acupressure of PC 6 acupoint is proven effective in a large trial it is a simple non-invasive intervention that could easily be incorporated into practice.

Direct extubation onto high-flow nasal cannulae post-cardiac surgery versus standard treatment in patients with a BMI ≥30: a randomised controlled trial.

PURPOSE: Patients with a body mass index (BMI) ≥30 kg/m(2) experience more severe atelectasis following cardiac surgery than those with normal BMI and its resolution is slower. This study aimed to compare extubation of patients post-cardiac surgery with a BMI ≥30 kg/m(2) onto high-flow nasal cannulae (HFNC) with standard care to determine whether HFNC could assist in minimising post-operative atelectasis and improve respiratory function. METHODS: In this randomised controlled trial, patients received HFNC or standard oxygen therapy post-extubation. The primary outcome was atelectasis on chest X-ray. Secondary outcomes included oxygenation, respiratory rate (RR), subjective dyspnoea, and failure of allocated treatment. RESULTS: One hundred and fifty-five patients were randomised, 74 to control, 81 to HFNC. No difference was seen between groups in atelectasis scores on Days 1 or 5 (median scores = 2, p = 0.70 and p = 0.15, respectively). In the 24-h post-extubation, there was no difference in mean PaO2/FiO2 ratio (HFNC 227.9, control 253.3, p = 0.08), or RR (HFNC 17.2, control 16.7, p = 0.17). However, low dyspnoea levels were observed in each group at 8 h post-extubation, median (IQR) scores were 0 (0-1) for control and 1 (0-3) for HFNC (p = 0.008). Five patients failed allocated treatment in the control group compared with three in the treatment group [Odds ratio 0.53, (95 % CI 0.11, 2.24), p = 0.40]. CONCLUSIONS: In this study, prophylactic extubation onto HFNC post-cardiac surgery in patients with a BMI ≥30 kg/m(2) did not lead to improvements in respiratory function. Larger studies assessing the role of HFNC in preventing worsening of respiratory function and intubation are required.

Marfan syndrome is associated with recurrent dissection of the dissected aorta.

BACKGROUND: Recurrent dissection of a previously dissected aortic segment has been reported as a rare, late complication in single case reports. The infrequency of this event makes informed risk assessment in an individual patient challenging. METHODS: To investigate this issue we examined the database of the Massachusetts General Hospital Thoracic Aortic Center between January 1, 2003 and December 31, 2012. A retrospective review was performed to identify patients with both (1) an acute aortic dissection after a prior aortic dissection and (2) evidence of a new dissection within a previously dissected aortic segment creating a triple lumen aorta. Data were reviewed to identify factors predisposing to dissection of a previously dissected aortic segment. RESULTS: Over a 10-year period we identified 5 cases of aortic dissection within a previously dissected aortic segment presenting as a new acute aortic syndrome. On average, the recurrent dissection occurred 1 decade after the first aortic dissection (mean = 9.8 ± 1.9 years). Patients identified in this series were significantly younger at first dissection and more likely to carry the diagnosis of Marfan syndrome. Aortic aneurysm diameter was quantified before and after the new dissection event and demonstrated a marked increase in aneurysmal size (mean increase = 1.6 ± 0.3 cm). CONCLUSIONS: We conclude that medial degeneration, as seen in the Marfan aorta, represents a predisposing factor for recurrent dissection of the dissected aorta. Our data indicate that double aortic dissections cause significant arterial destabilization and a low threshold for surgical intervention is appropriate.

The quality of intensive care unit nurse handover related to end of life: a descriptive comparative international study.

BACKGROUND: Quality ICU end-of-life-care has been found to be related to good communication. Handover is one form of communication that can be problematic due to lost or omitted information. A first step in improving care is to measure and describe it. OBJECTIVE: The objective of this study was to describe the quality of ICU nurse handover related to end-of-life care and to compare the practices of different ICUs in three different countries. DESIGN: This was a descriptive comparative study. SETTINGS: The study was conducted in seven ICUs in three countries: Australia (1 unit), Israel (3 units) and the UK (3 units). PARTICIPANTS: A convenience sample of 157 handovers was studied. METHODS: Handover quality was rated based on the ICU End-of-Life Handover tool, developed by the authors. RESULTS: The highest levels of handover quality were in the areas of goals of care and pain management while lowest levels were for legal issues (proxy and advanced directives) related to end of life. Significant differences were found between countries and units in the total handover score (country: F(2,154)=25.97, p=<.001; unit: F(6,150)=58.24, p=<.001), for the end of life subscale (country: F(2, 154)=28.23, p<.001; unit: F(6,150)=25.25, p=<.001), the family communication subscale (country: F(2,154)=15.04, p=<.001; unit: F(6,150)=27.38, p=<.001), the family needs subscale (F(2,154)=22.33, p=<.001; unit: F(6,150)=42.45, p=<.001) but only for units on the process subscale (F(6,150)=8.98, p=<.001. The total handover score was higher if the oncoming RN did not know the patient (F(1,155)=6.51, p=<.05), if the patient was expected to die during the shift (F(1,155)=89.67, p=<.01) and if the family were present (F(1,155)=25.81, p=<.01). CONCLUSIONS: Practices of end-of-life-handover communication vary greatly between units. However, room for improvement exists in all areas in all of the units studied. The total score was higher when quality of care might be deemed at greater risk (if the nurses did not know the patient or the patient was expected to die), indicating that nurses were exercising some form of discretionary decision making around handover communication; thus validating the measurement tool.