Urinary Retention Evaluation and Catheterization Algorithm for Adult Inpatients.

Importance: Acute urinary retention (UR) is common, yet variations in diagnosis and management can lead to inappropriate catheterization and harm. Objective: To develop an algorithm for screening and management of UR among adult inpatients. Design, Setting, and Participants: In this mixed-methods study using the RAND/UCLA Appropriateness Method and qualitative interviews, an 11-member multidisciplinary expert panel of nurses and physicians from across the US used a formal multi-round process from March to May 2015 to rate 107 clinical scenarios involving diagnosis and management of adult UR in postoperative and medical inpatients. The panel ratings informed the first algorithm draft. Semistructured interviews were conducted from October 2020 to May 2021 with 33 frontline clinicians-nurses and surgeons from 5 Michigan hospitals-to gather feedback and inform algorithm refinements. Main Outcomes and Measures: Panelists categorized scenarios assessing when to use bladder scanners, catheterization at various scanned bladder volumes, and choice of catheterization modalities as appropriate, inappropriate, or uncertain. Next, qualitative methods were used to understand the perceived need, usability, and potential algorithm uses. Results: The 11-member expert panel (10 men and 1 woman) used the RAND/UCLA Appropriateness Method to develop a UR algorithm including the following: (1) bladder scanners were preferred over catheterization for UR diagnosis in symptomatic patients or starting as soon as 3 hours since last void if asymptomatic, (2) bladder scanner volumes appropriate to prompt catheterization were 300 mL or greater in symptomatic patients and 500 mL or greater in asymptomatic patients, and (3) intermittent was preferred to indwelling catheterization for managing lower bladder volumes. Interview findings were organized into 3 domains (perceived need, feedback on algorithm, and implementation suggestions). The 33 frontline clinicians (9 men and 24 women) who reviewed the algorithm reported that an evidence-based protocol (1) was needed and could be helpful to clinicians, (2) should be simple and graphically appealing to improve rapid clinician review, and (3) should be integrated within the electronic medical record and prominently displayed in hospital units to increase awareness. The draft algorithm was iteratively refined based on stakeholder feedback. Conclusions and Relevance: In this study using a systematic, multidisciplinary, evidence- and expert opinion-based approach, a UR evaluation and catheterization algorithm was developed to improve patient safety by increasing appropriate use of bladder scanners and catheterization. This algorithm addresses the need for practical guidance to manage UR among adult inpatients.

Defining Benchmarks for Pelvic Exenteration Surgery: A Multicentre Analysis of Patients with Locally Advanced and Recurrent Rectal Cancer.

OBJECTIVE: To establish globally applicable benchmark outcomes for pelvic exenteration (PE) in patients with locally advanced primary (LARC) and recurrent rectal cancer (LRRC), using outcomes achieved at highly specialised centres. BACKGROUND DATA: PE is established as the standard of care for selected patients with LARC and LRRC. There are currently no available benchmarks against which surgical performance in PE can be compared for audit and quality improvement. METHODS: This international multicentre retrospective cohort study included patients undergoing PE for LARC or LRRC at 16 highly experienced centres between 2018 and 2023. Ten outcome benchmarks were established in a lower-risk subgroup. Benchmarks were defined by the 75th percentile of the results achieved at the individual centres. RESULTS: 763 patients underwent PE, of which 464 patients (61%) had LARC and 299 (39%) had LRRC. 544 patients (71%) who met predefined lower risk criteria formed the benchmark cohort. For LARC patients, the calculated benchmark threshold for major complication rate was ≤44%; comprehensive complication index (CCI): ≤30.2; 30-day mortality rate: 0%; 90-day mortality rate: ≤4.3%; R0 resection rate: ≥79%. For LRRC patients, the calculated benchmark threshold for major complication rate was ≤53%; CCI: ≤34.1; 30-day mortality rate: 0%; 90-day mortality rate: ≤6%; R0 resection rate: ≥77%. CONCLUSIONS: The reported benchmarks for PE in patients with LARC and LRRC represent the best available care for this patient group globally and can be used for rigorous assessment of surgical quality and to facilitate quality improvement initiatives at international exenteration centres.

The role of hospital-based vascular access teams and implications for patient safety: A multi-methods study.

BACKGROUND: Peripherally inserted central catheters (PICCs) and midline catheters are often placed by nurse-led vascular access teams (VATs). While some data regarding the effectiveness of these teams exists, less is known about their structure and function. OBJECTIVES: To examine the roles, functions, and composition of VATs related to the use and management of PICC and midline catheters. METHODS: A descriptive, multi-method study that included an online survey of 62 hospitals participating in a quality improvement consortium and qualitative interviews with 74 hospital-based clinicians in 10 sites. Interviews were recorded, transcribed, and analyzed using a rapid analysis and matrix approach. The survey, which contained closed-ended, categorical questions, was analyzed using frequencies and percentages. RESULTS: More than 77% (n = 48) of hospitals had an on-site VAT. The average team size was seven nurses; their primary function was device insertion. Interview findings revealed that teams varied in characteristics and functions. Interviewees described the broad role that teams play in device insertion, care and removal, and in educating/training hospital staff. However, we found that teams' role in decision making, particularly related to appropriate device selection, was limited and, in some cases, met with physician resistance. CONCLUSIONS: To realize the full benefit of VATs, changes in hospital culture, along with an increased willingness from physicians to integrate VAT nurses in decision making, may be needed. Future interventions aimed at engaging and empowering teams appear necessary.

Effect of differing flap reconstruction strategies in perineal closure following advanced pelvic oncological resection: a retrospective cohort study.

INTRODUCTION: Advancing approaches to locally invasive pelvic malignancy creates a large tissue defect resulting in perineal wound complications, dehiscence, and perineal hernia. Use of reconstructive flaps such as vertical rectus abdominus myocutaneous (VRAM) flap, gracilis, anterolateral thigh and gluteal flaps have been utilised in our institution to address perineal closure. The authors compared outcomes using different flap techniques along with primary perineal closure in advanced pelvic oncological resection. METHODS: A prospectively maintained database of patients undergoing advanced pelvic oncological resection in a single tertiary hospital was retrospectively analysed. This study included consecutive patients between 2014 and 2021 according to the Strengthening The Reporting of Cohort Studies in Surgery (STROCSS) criteria. Primary outcome measures were the frequency of postoperative perineal complications between primary closure, VRAM, gluteal and thigh (anterolateral thigh and gracilis) reconstruction. RESULTS: One hundred twenty-two patients underwent advanced pelvic resection with perineal closure. Of these, 40 patients underwent extra-levator abdominoperineal resection, and 70 patients underwent pelvic exenteration. Sixty-four patients received reconstructive flap closure, which included VRAM (22), gluteal (21) and thigh flaps (19). Perineal infection and dehiscence rates were low. Infection rates were lower in the flap group despite a higher rate of radiotherapy ( P <0.050). Reoperation rates were infrequent (<10%) but specific for each flap, such as donor-site hernia following VRAM and flap dehiscence after thigh flap reconstruction. CONCLUSIONS: In patients who are at high risk of postoperative perineal infections, reconstructive flap closure offers acceptable outcomes. VRAM, gluteal and thigh flaps offer comparable outcomes and can be tailored to the individual patient.

A descriptive study of policy and system-level interventions to address cancer survivorship issues across six United States health systems.

PURPOSE: To describe policy and system-level interventions with potential to improve cancer care at six sites. METHODS: In 2016, six institutions received foundation support to develop unique multi-component interventions aimed at improving cancer care for underserved populations. These organizations, located across the United States, participated in a cross-site evaluation to assess the overall initiative impact and to identify potentially promising policy and system-level solutions for dissemination and broader implementation. A health system and policy tracking tool was developed to collect data from each site and included a description of their efforts, strategies employed, and changes achieved (e.g., new policies, clinical protocols). Tracking tool data were analyzed using rapid qualitative analyses and a matrix approach. Semi-structured interviews were conducted with site leaders (N = 65) and were analyzed by thematic analysis. RESULTS: Sites reported 20 system and policy efforts, which resulted in improvements to electronic health records and telehealth strategies, changes to hospital/health system policies, and standardized clinical protocols/guidelines, among others. Efforts were aimed at: (1) coordinating care across multiple providers, supported by patient navigators; (2) expanding psychosocial and supportive care; (3) improving patient-provider communication; and (4) addressing barriers to accessing care. Interview analyses provided insights into successful strategies, challenges, and implications of the COVID-19 pandemic on cancer care. CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS: Despite advances in diagnosis and treatment, cancer care remains inequitable. System-level improvements aimed at eliminating common barriers faced by underserved populations offer opportunities to improve the delivery of equitable, effective, and efficient care.

Assessment of inter-centre agreement across multidisciplinary team meetings for patients with retroperitoneal sarcoma.

BACKGROUND: Decision-making in the management of patients with retroperitoneal sarcoma is complex and requires input from a number of different specialists. The aim of this study was to evaluate the levels of agreement in terms of resectability, treatment allocation, and organs proposed to be resected across different retroperitoneal sarcoma multidisciplinary team meetings. METHODS: The CT scans and clinical information of 21 anonymized retroperitoneal sarcoma patients were sent to all of the retroperitoneal sarcoma multidisciplinary team meetings in Great Britain, which were asked to give an opinion about resectability, treatment allocation, and organs proposed to be resected. The main outcome was inter-centre reliability, which was quantified using overall agreement, as well as the chance-corrected Krippendorff's alpha statistic. Based on the latter, the level of agreement was classified as: 'slight' (0.00-0.20), 'fair' (0.21-0.40), 'moderate' (0.41-0.60), 'substantial' (0.61-0.80), or 'near-perfect' (>0.80). RESULTS: Twenty-one patients were reviewed at 12 retroperitoneal sarcoma multidisciplinary team meetings, giving a total of 252 assessments for analysis. Consistency between centres was only 'slight' to 'fair', with rates of overall agreement and Krippendorff's alpha statistics of 85.4 per cent (211 of 247) and 0.37 (95 per cent c.i. 0.11 to 0.57) for resectability; 80.4 per cent (201 of 250) and 0.39 (95 per cent c.i. 0.33 to 0.45) for treatment allocation; and 53.0 per cent (131 of 247) and 0.20 (95 per cent c.i. 0.17 to 0.23) for the organs proposed to be resected. Depending on the centre that they had attended, 12 of 21 patients could either have been deemed resectable or unresectable, and 10 of 21 could have received either potentially curative or palliative treatment. CONCLUSIONS: Inter-centre agreement between retroperitoneal sarcoma multidisciplinary team meetings was low. Multidisciplinary team meetings may not provide the same standard of care for patients with retroperitoneal sarcoma across Great Britain.

Reaching Populations to Address Disparities in Cancer Care Delivery: Results From a Six-Site Initiative.

BACKGROUND: Large segments of the US population do not receive quality cancer care due to pervasive and systemic inequities, which can increase morbidity and mortality. Multicomponent, multilevel interventions can address inequities and improve care, but only if they reach communities with suboptimal access. Intervention studies often underenroll individuals from historically excluded groups. METHODS: The Alliance to Advance Patient-Centered Cancer Care includes 6 grantees across the United States who implemented unique multicomponent, multilevel intervention programs with common goals of reducing disparities, increasing engagement, and improving the quality of care for targeted populations. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework informed the evaluation efforts across sites. Each Alliance site identified their intended populations, which included underrepresented minorities (eg, Black and Latinx persons), individuals who prefer a language other than English, and rural residents. We evaluated the demographic characteristics of participants to determine program reach. RESULTS: Between 2018 and 2020, a total of 2,390 of 5,309 potentially eligible participants were enrolled across the 6 sites. The proportion of enrolled individuals with selected characteristics included 38% (n=908) Black adults, 24% (n=574) Latinx adults, 19% (n=454) preferring a language other than English, and 30% (n=717) rural residents. The proportion of those enrolled who were the intended population was commensurate to the proportion with desired characteristics in those identified as potentially eligible. CONCLUSIONS: The grantees met or exceeded enrollments from their intended populations who have been underserved by quality cancer care into patient-centered intervention programs. Intentional application of recruitment/engagement strategies is needed to reach individuals from historically underserved communities.

Paddling Together: Water Trails as Innovative Public Health Strategies.

BACKGROUND: Blueways can help improve health and quality-of-life by providing places for exercise, recreation, and community gatherings. The Rouge River Watershed is an industrialized region in Southeast Michigan with high rates of chronic disease and historic disinvestment in social and environmental conditions. The purpose of this article is to describe the process taken to develop an equitable, community-driven vision and approach for developing a water trail along the Lower Rouge River and to identify the key elements that emerged. METHODS UTILIZED TO CREATE A COMMUNITY-DRIVEN APPROACH: Project leaders incorporated community-driven planning, community outreach, and community ownership strategies. The Rouge River Water Trail Leadership Committee engages the public, those affected by decisions, with a transparent, fact-based process. The public is given equal status and shares decision-making authority. INITIAL RESULTS: This approach led to the development of a Water Trail Strategic Plan, community-informed recommendations for capital improvements, development of key relationships, and coalitions that provide a vehicle for ongoing community engagement and ownership. Five main elements, considered through an equity lens, go into building a water trail: (1) creating access points, (2) water quality monitoring, (3) woody debris management, (4) signage, and (5) developing a safety plan. IMPLICATIONS FOR PRACTICE, POLICY, AND RESEARCH: Water trail development should consist of (1) environmental change through the creation of access points and safe, navigable waterways and (2) opportunities to utilize the infrastructure through programming and initiatives to make the trail accessible to all communities.

Exploring Sacred Moments in Hospitalized Patients: An Exploratory Qualitative Study.

BACKGROUND: "Sacred moments" are brief periods of time in which people experience a deep interconnectedness that may possess spiritual qualities and emotions. This concept has been shown to have a positive impact on individuals' overall well-being and stress in mental health settings. The concept of sacred moments has not been studied in acute care hospital settings. OBJECTIVE: To better understand the occurrence of sacred moments among hospitalized patients and their healthcare workers. DESIGN: An exploratory qualitative study that included in-depth interviews with patients and healthcare workers at two academic medical centers in the Midwestern United States. PARTICIPANTS: Hospital healthcare workers (e.g., physicians, nurses, ancillary staff) and discharged patients with a recent hospital stay. APPROACH: Semi-structured telephone interviews were conducted with 30 participants between August 2020 and April 2021. Interviews were recorded and transcribed before conducting thematic analysis. KEY RESULTS: Both healthcare workers and patients reported having experienced at least one sacred moment. Interview findings were organized into three main domains including (1) several common elements described by participants as marking these moments; (2) benefits experienced by both patients and healthcare workers; and (3) suggestions for fostering sacred moments within the hospital setting. CONCLUSIONS: Among our participants, sacred moments were extremely common with the vast majority reporting to have experienced at least one in their lifetime. These moments were described as profound and important and shared many common elements. Our findings can be used to help recognize, understand, and promote sacred moments between hospitalized patients and healthcare workers.

"They Kept Going for Answers": Knowledge, Capacity, and Environmental Health Literacy in Michigan's PBB Contamination.

The Michigan PBB Oral History Project documented community residents' descriptions of a large-scale chemical contamination-the PBB contamination-that occurred in Michigan in 1973. These oral histories document residents' and others' experiences during and after the contamination. We conducted a grounded theory qualitative analysis of 31 oral histories to examine the experiences of community members, researchers, lawyers, and others who actively sought out and contributed essential information about the contamination and its impacts. Our findings highlight several challenges encountered in the development of this knowledge including four central themes-contested knowledge, community skills, inaction, and uncertainty. Integrating environmental health literacy, community capacity, and contested illness frameworks, we examine the contributions of community residents, scientists (from inside and outside the community), and others to the development of knowledge to inform decisions and sustain action regarding this large-scale contamination. We close with a discussion of lessons learned regarding efforts to build environmental health knowledge within uncertain and often contested contexts and for promoting environmental health and action related to large-scale chemical contaminations. Our findings suggest the importance of integrated frameworks for examining and promoting the critical role of community skills, leadership, participation, sense of community, and community power in promoting environmental health.

Prevention and management of complications in pelvic exenteration.

Pelvic exenteration is widely recognised as the gold standard of care for locally advanced tumours of the pelvis. Surgery in pursuit of curative resection comes at the cost of significant morbidity. Perioperative complications are commonplace with the majority managed without further surgical intervention. Boundaries of resection are expanding, resulting in increasing incidence of excision of major vascular structures and bone. Optimisation of patients is paramount prior to such significant surgical insult. Specialist centres with designated multidisciplinary teams should be used whenever possible. Addressing anaemia and nutrition play a significant role in prehabilitation. Intra-operatively consideration should be given to prevention of empty pelvis syndrome, perineal reconstruction, safe control of vascular structures and minimising risk of fistulae. Post-operative complications are common however employment of enhanced recovery protocols, minimally invasive surgery and opiate sparing analgesia protocols may in time lead to improvements for patients. Enteric fistulae and urine leak remain the most devastating and risk reduction strategies should be employed. Early recognition and aggressive management of complications is essential.

Low-income mothers' perspectives on the involvement of family members in child feeding.

Nearly all research on child feeding has focused on mothers. Very little is known about other family members' roles in feeding children nor how mothers engage with these family members regarding child feeding. The objective of this study was to examine mothers' perceptions of other family members' child feeding roles and practices within low-income families, including the challenges experienced and strategies employed by mothers when sharing responsibility for child feeding. Low-income mothers (n = 100) of pre-adolescent children participated in semi-structured interviews regarding child feeding including shared responsibility for child feeding. A content analysis was then conducted to identify main themes in mothers' responses, with three main themes arising from the interviews. First, many family members were actively involved in child feeding and food-related decision-making. The majority of mothers (85%) reported that another family member was involved in feeding their child including fathers and father figures, who were involved in feeding in 63% of families. Other family members, mainly grandparents, were involved in feeding in 35% of families. Mothers identified several concerns regarding their child's eating when with other family members, particularly when grandparents fed children. Finally, mothers employed several strategies to control their children's eating when children were cared for by other family members. Future interventions to promote healthy child feeding among low-income families may benefit from helping mothers negotiate child feeding with other family members, particularly grandparents, and supporting family members' engagement in child feeding.

Support opportunities for second victims lessons learned: a qualitative study of the top 20 US News and World Report Honor Roll Hospitals.

BACKGROUND: Second Victim Programs (SVPs) provide support for healthcare providers involved in a near-miss, medical error, or adverse patient outcomes. Little is known about existence and structure of SVPs in top performing US hospitals. METHODS: We performed a prospective study and interviewed individuals representing SVPs from 20 US News and World Report (USNWR) Honor Roll Hospitals. Telephone interviews were recorded, transcribed, and de-identified. To allow identification of both quantitative and qualitative themes that unified or distinguished programs with SVPs from each other, a content analysis approach was used. RESULTS: Of the Top 20 UNSWR hospitals, nineteen individuals with knowledge of or involvement in SVPs were identified. One individual represented two hospital systems for the same institution. Thirteen representatives agreed to participate, 12 declined, and 5 did not respond. One individual who initially agreed to participate did not attend the interview. Among twelve representatives interviewed, 10 reported establishment of SVPs at their hospitals between 2011 and 2016. Most program representatives reported that participants sought support voluntarily. Four domains were identified in the qualitative analysis: (a) identification of need for Second Victim Program (SVP); (b) challenges to program viability; (c) structural changes following SVP creation, and (d) insights for success. Driving SVP creation was the need support medical providers following a traumatic patient event. Poor physician participation due to the stigma associated with seeking support was commonly reported as a challenge. However, acceptance of the mission of SVPs, growing recognition of the value of the program across hospital departments, and systematic safety enhancements were cited as key advantages. To ensure success, participants suggested training a variety of volunteers and incorporating SVPs within quality improvement processes. CONCLUSIONS: In this convenience sample, programs for healthcare providers that experience psychosocial or emotional trauma from clinical care were uncommon. Variation in structure, performance, and measures of success among SVPs was observed. A systematic approach to evaluating SVPs is needed to help inform institutions of how to best serve their second victims.

Comparing peripherally inserted central catheter-related practices across hospitals with different insertion models: a multisite qualitative study.

BACKGROUND: Peripherally inserted central catheters (PICCs) provide reliable intravenous access for delivery of parenteral therapy. Yet, little is known about PICC care practices or how they vary across hospitals. We compared PICC-related processes across hospitals with different insertion delivery models. METHODS: We used a descriptive qualitative methodology and a naturalist philosophy, with site visits to conduct semistructured interviews completed between August 2018 and January 2019. Study sites included five Veterans Affairs Medical Centres, two with vascular access teams (VATs), two with PICC insertion primarily by interventional radiology (IR) and one without on-site PICC insertion capability. Interview participants were healthcare personnel (n=56), including physicians, bedside and vascular access nurses, and IR clinicians. Data collection focused on four PICC domains: use and decision-making process, insertion, in-hospital management and patient discharge education. We used rapid analysis and a summary matrix to compare practices across sites within each domain. RESULTS: Our findings highlight the benefits of dedicated VATs across all PICC-related process domains, including implementation of criteria to guide PICC placement decisions, timely PICC insertion, more robust management practices and well-defined patient discharge education. We also found areas with potential for improvement, such as clinician awareness of PICC appropriateness criteria and alternative devices, deployment of VATs and patient discharge education. CONCLUSION: Vascular access nurses play critical roles in all aspects of PICC-related care. There is variation in PICC decision-making, care and maintenance, and patient education across hospitals. Quality and safety improvement opportunities to reduce this variation are highlighted.

The variability in how physicians think: a casebased diagnostic simulation exercise.

OBJECTIVES: Little is known about how physician diagnostic thinking unfolds over time when evaluating patients. We designed a case-based simulation to understand how physicians reason, create differential diagnoses, and employ strategies to achieve a correct diagnosis. METHODS: Between June 2017 and August 2018, hospital medicine physicians at two academic medical centers were presented a standardized case of a patient presenting with chest pain who was ultimately diagnosed with herpes zoster using an interview format. Case information was presented in predetermined aliquots where participants were then asked to think-aloud, describing their thoughts and differential diagnoses given the data available. At the conclusion of the interview, participants were asked questions about their diagnostic process. Interviews were recorded, transcribed, and content analysis was conducted to identify key themes related to the diagnostic thinking process. RESULTS: Sixteen hospital medicine physicians (nine men, seven women) participated in interviews and four obtained the correct final diagnosis (one man, three women). Participants had an average of nine years of experience. Overall, substantial heterogeneity in both the differential diagnoses and clinical reasoning among participants was observed. Those achieving the correct diagnosis utilized systems-based or anatomic approaches when forming their initial differential diagnoses, rather than focusing on life-threatening diagnoses alone. Evidence of cognitive bias was common; those with the correct diagnosis more often applied debiasing strategies than those with the incorrect final diagnosis. CONCLUSIONS: Heterogeneity in diagnostic evaluation appears to be common and may indicate faulty data processing. Structured approaches and debiasing strategies appear helpful in promoting diagnostic accuracy.

Visual arts in the clinical clerkship: a pilot cluster-randomized, controlled trial.

BACKGROUND: Arts exposure is associated with positive psychological constructs. To date, no randomized, controlled studies have integrated art into clinical medical education or measured its effects on positive psychological constructs or educational outcomes. In this study, we assessed the possibility and potential benefits of integrating visual arts education into a required internal medicine (IM) clinical clerkship. METHODS: We conducted a controlled trial in an academic healthcare system with an affiliated art museum. IM students were assigned to one of three interventions: museum-based arts (n = 11), hospital-based arts (n = 10), or hospital-based conventional education (n = 13). Arts groups explored empathy, resilience, and compassion in works of art during facilitator-guided discussions. We assessed pre- and post-intervention measures of empathy, mindfulness, tolerance of ambiguity, and grit and tracked National Board of Medical Examiners IM shelf exam performance to capture changes in educational outcomes. Focus group discussions with participants in the arts-based interventions were performed at the study's conclusion. RESULTS: Arts education was successfully integrated into a busy clinical clerkship in both hospital and art museum settings. Focus group participants reported increased implicit bias cognizance and time for reflection, but no significant differences in psychometric or educational outcomes were identified. While most students felt positively toward the experience; some experienced distress from missed clinical time. CONCLUSIONS: This pilot study demonstrates the feasibility of integrating visual arts education into the clerkship. Although observable quantitative differences in measures of positive psychological constructs and educational outcomes were not found, qualitative assessment suggested benefits as well as the feasibility of bringing fine arts instruction into the clinical space. A larger, multi-center study is warranted.

Strategies of Female Teaching Attending Physicians to Navigate Gender-Based Challenges: An Exploratory Qualitative Study.

BACKGROUND: Women in medicine experience discrimination, hostility, and unconscious bias frequently and with deleterious effects. While these gender-based challenges are well described, strategies to navigate and respond to them are less understood. OBJECTIVE: To explore the lived experiences of female teaching attending physicians emphasizing strategies they use to mitigate gender-based challenges in clinical environments. DESIGN: Multisite exploratory, qualitative study. SETTING: Inpatient general medicine teaching rounds in six geographically diverse US academic hospitals between April and August 2018. PARTICIPANTS: With use of a modified snowball sampling approach, female attendings and their learners were identified; six female attendings and their current (n = 24) and former (n = 17) learners agreed to participate. MEASUREMENTS: Perceptions of gender-based challenges in clinical teaching environments and strategies with which to respond to these challenges were evaluated through semistructured in-depth interviews, focus group discussions, and direct observations of rounds. Observations were documented using handwritten field notes. Interviews and focus groups were audio recorded and transcribed. All transcripts and field note data were analyzed using a content analysis approach. MAIN OUTCOMES: Attending experience levels ranged from 8 to 20 years (mean, 15.3 years). Attendings were diverse in terms of race/ethnicity. Strategic approaches to gender-based challenges clustered around three themes: female attendings (1) actively position themselves as physician team leaders, (2) consciously work to manage gender-based stereotypes and perceptions, and (3) intentionally identify and embrace their unique qualities. CONCLUSION: Female attendings manage their roles as women in medicine through specific strategies to both navigate complex gender dynamics and role model approaches for learners.

Using Democratic Deliberation to Engage Veterans in Complex Policy Making for the Veterans Health Administration.

A democratic deliberation panel of veterans providing insight into veteran perspectives on resource allocation and the Veterans Choice Act showed the importance and feasibility of engaging veterans in the policy-making process.

Persistent Barriers to Timely Catheter Removal Identified from Clinical Observations and Interviews.

BACKGROUND: Indwelling urinary and vascular catheters are valuable devices in patient care, but prolonged or unnecessary use increases the risk of infectious and noninfectious catheter harms. METHODS: To understand persistent barriers to detecting and removing unnecessary catheters, researchers conducted a multimethod qualitative study that included observations and in-person interviews with clinicians working on a progressive care unit of a large hospital. Observations consisted of shadowing nurses during shift change and while admitting patients, and observing physicians during morning rounds. Observational data were gathered using unstructured field notes. Interviews were conducted using a semistructured guide, audio-recorded, and transcribed. Qualitative content analysis was conducted to identify main themes. RESULTS: Barriers to timely removal identified during 19 interviews with clinicians and 133 hours of field observations included physicians not routinely reviewing catheter necessity during rounds, catheters going unnoticed or hidden under clothing, common use of "Do Not Remove" orders, and little or no discussion of catheters among clinicians. Five overall themes emerged: (1) Catheter data are hard to find, not accurate, or not available; (2) Catheter removal is not a priority; (3) Confusion exists about who has authority to remove catheters; (4) There is a lack of agreement on, and awareness of, standard protocols and indications for removal; and (5) Communication barriers among clinicians create challenges. CONCLUSION: To address barriers and facilitate detection and timely removal, clinicians need ready access to accurate catheter data, more clearly delineated clinician roles for prompting removal, effective tools to facilitate discussions about catheter use, and standardized catheter removal protocols.

Do bedside whiteboards enhance communication in hospitals? An exploratory multimethod study of patient and nurse perspectives.

OBJECTIVE: To understand patient and nurse views on usability, design, content, barriers and facilitators of hospital whiteboard utilisation in patient rooms. DESIGN: Multimethods study. SETTING: Adult medical-surgical units at a quaternary care academic centre. PARTICIPANTS: Four hundred and thirty-eight adult patients admitted to inpatient units participated in bedside surveys. Two focus groups with a total of 13 nurses responsible for updating and maintaining the whiteboards were conducted. RESULTS: Most survey respondents were male (55%), ≥51 years of age (69%) and admitted to the hospital ≤4 times in the past 12 months (90%). Over 95% of patients found the whiteboard helpful and 92% read the information on the whiteboard frequently. Patients stated that nurses, not doctors, were the most frequent user of whiteboards (93% vs 9.4%, p<0.001, respectively). Patients indicated that the name of the team members (95%), current date (87%), upcoming tests/procedures (80%) and goals of care (63%) were most useful. While 60% of patients were aware that they could use the whiteboard for questions/comments for providers, those with ≥5 admissions in the past 12 months were significantly more likely to be aware of this aspect (p<0.001). In focus groups, nurses reported they maintained the content on the boards and cited lack of access to clinical information and limited use by doctors as barriers. Nurses suggested creating a curriculum to orient patients to whiteboards on admission, and educational programmes for physicians to increase whiteboard utilisation. CONCLUSION: Bedside whiteboards are highly prevalent in hospitals. Orienting patients and their families to their purpose, encouraging daily use of the medium and nurse-physician engagement around this tool may help facilitate communication and information sharing.