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Purpose/Objective(s) A United States (US) radiation oncology (RO) curriculum, developed by key stakeholders using best practices for curriculum inquiry, is needed to guide residency education and qualifying examinations. Competency-based training, including entrustable professional activities (EPAs), provides an outcomes-based approach to modern graduate medical education. This study developed the first list of US RO EPAs and curricular content domains (CDs) to guide resident training and assessment in the modern era. Materials/Methods The Radiation Oncology Education Collaborative Study Group (ROECSG) Core Curriculum Project Leadership Committee (LC) developed initial EPAs and CDs. Following recruitment of stakeholders, a Delphi process was used for consensus. In the first Delphi, EPAs and CDs were reviewed for inclusion/exclusion, clarity, level of training (EPAs only), and time allocation (CDs only). Participants submitted additional EPAs/CDs for consideration. Any EPA or CD one standard deviation below the median underwent LC review. All participants completing the first Delphi were invited to the second. New EPAs or EPAs undergoing major revisions were re-reviewed. Percent allocated curriculum time was finalized for CDs and for a single subdomain (SD). Results 186 participants representing diverse RO stakeholder groups volunteered to participate. 114 completed the first Delphi (61.3%): 6/9 CDs met consensus, 1 CD was removed, 2 CDs were combined (Table 1). Of 114 invited, 77 participants completed the second Delphi (67.5%). Of 55 initial EPAs, 52 final EPAs met consensus. 4 SDs of a single CD (Applied Sciences) were reviewed and met consensus. Consensus on percent time allocated per CD and SD was reached (Table 1). Conclusion Deliberative curriculum inquiry was successfully used to develop a consensus on US RO CDs/SDs and EPAs. These data can guide educational time in training programs and help inform weighting for qualifying examinations. CDs are not exclusive; educators must ensure all CDs are considered when delivering curriculum content, regardless of the primary CD. RO-specific EPAs can guide clinical training and resident assessment. The Delphi should be used to reach consensus recommendations for SD content breakdown. Given the evolving nature of RO and the need for curriculum renewal, the Delphi process will be repeated on an interval basis.

Introduction While brief and fragmented accounts of the differences between systems have been noted in the literature, until recently there has been a lack of research that explores and identifies new sub-models of paramedicine within the Anglo-American paramedic system. Methods A Delphi method was used to gain consensus among international paramedic experts regarding two new models of paramedicine known as the Directive and Professionally Autonomous paramedic systems. Following the development of a preliminary definition, a set of questions were established for experts aimed at defining the new sub-models; the responses were reviewed and amended based on feedback before being re-distributed to an expanded group of participants for further rounds of questions. Rounds continued until consensus was achieved. Results Consensus was achieved for both statements regarding the Professionally Autonomous paramedic system definition in round 2, 85.7% (n = 18). Following analysis and revision of the definition, the additional two statements regarding the Directive paramedic system achieved consensus in round 3, 100% (n = 19). Conclusion This Delphi study was the first study to explore a standardised definition for two newly identified sub-models of the Anglo-American paramedic system with the overall results used to help inform high performing system design for modern Anglo-American paramedic systems into the future.

Purpose Traumatic brain injury (TBI) is one of the major public health concerns worldwide. Developing a TBI registry could facilitate characterizing TBI, monitoring the quality of care, and quantifying the burden of TBI by collecting comparable and standardized epidemiological and clinical data. However, a national standard tool for data collection of the TBI registry has not been developed in Iran yet. This study aimed to develop a national minimum data set (MDS) for a hospital-based registry of patients suffering from TBI in Iran. Methods The MDS was designed in two phases, including a literature review and a Delphi study with content validation by an expert panel. After the literature review, a comprehensive list of administrative and clinical items was obtained. Through a two-round e-Delphi approach conducted by invited experts with clinical and research experience in the field of TBI, the final data elements were selected. Results An MDS of TBI was assigned to two parts: administrative part with 5 categories including 52 data elements, and clinical part with 9 categories including 130 data elements. Conclusion For the first time in Iran, we developed an MDS specified for TBI consisting of 182 data elements. The MDS would facilitate implementing a TBI's national level registry and providing essential, comparable, and standardized information.

Background Value-based contracts that tie payments for pharmaceuticals to predefined outcomes aim to promote value through shared risk and aligned incentives between manufacturers and payers. Methods We conducted a Delphi study among diverse stakeholders (patients, providers, payers, pharmacy benefits managers, pharmaceutical company representatives) to identify top meaningful outcomes for inclusion in value-based contracts for atrial fibrillation medications. The final panel (n = 55) rated the importance of each outcome on a 5-point Likert scale and selected their top 3 most meaningful outcomes. Non-patient participants rated the feasibility of collecting each outcome on a 5-point Likert scale. Consensus was defined as ≥75% agreement (Likert scores ≥4/5 or selection of an outcome as most meaningful). Differences between stakeholder groups were examined using Fisher's Exact Test. Results Consensus was achieved for importance of 10 outcomes (Likert scale), where “preventing stroke or mini-stroke” reached 100% agreement (55/55). Eighty-one percent (44/54) of participants selected “preventing stroke or mini-stroke” as the most meaningful outcome (rank order question). The measures rated as most feasibly collected were “reducing hospitalizations” (97%, 36/37) followed by “preventing stroke or mini-stroke” and “reducing emergency department visits” (both 92%, 34/37). There were statistically significant differences between patients and non-patients [0% (0/17) vs 22% (8/37), P = 0.047] and patients and providers [0% (0/17) vs 39% (7/18), P = 0.008] in selection of “improving health-related quality of life” as a most meaningful outcome. Conclusions These findings will inform the design of atrial fibrillation value-based pharmaceutical contracts and provide additional insight into preferences for outcomes which could be used to improve the quality of atrial fibrillation care.

OBJECTIVE Translation and cross-cultural adaptation to the Spanish context of the Place Standard tool to undertake participatory evaluations in place-based communities. METHOD A back-translation method was used to obtain an adapted version of the original Place Standard tool. The translated version was reviewed by a multidisciplinary committee of experts and validated using the Delphi method. RESULTS The final version of the adapted Place Standards tool (Entornos de Vida in Spanish) consists of 14 dimensions and 99 items. 21% of the items presented semantic difficulties during the translation. Total consensus through the Delphi panel was reached on 72% of the items. The analysis resulted in changes to the wording, and organization of the items, and the inclusion of new or modified questions to reflect the characteristics of the Spanish context. CONCLUSIONS The validation of the Entornos de Vida tool will enable the evaluation of place-based communities characteristics/physical and socio-economic contexts in a participatory and equitable manner that focuses on social determinants of health. Its application in scenarios that take into account processes of local health action will support the practice of health promotion and equity, and centre the attention and action on the physical and socio-economic contexts with the aim to learn how places and municipal policies can affect health and well-being.

Background Clinical guidelines on infection control strategies in healthcare workers (HCWs) play an important role in protecting them during the severe acute respiratory syndrome coronavirus 2 pandemic. Poorly constructed guidelines that are incomprehensive and/or ambiguous may compromise HCWs’ safety. Objective The objective of this study was to develop and validate a tool to appraise guidelines on infection control strategies in HCWs based on the guidelines published early in the coronavirus disease 2019 pandemic. Design, setting, and outcomes A three-stage, web-based, Delphi consensus-building process among a panel of diverse HCWs and healthcare managers was performed. The tool was validated by appraising 40 international, specialty-specific, and procedure-specific guidelines along with national guidelines from countries with a wide range of gross national income. Results Overall consensus (≥75%) was reached at the end of three rounds for all six domains included in the tool. The Delphi panel recommended an ideal infection control guideline should encompass six domains: general characteristics (domain 1), engineering recommendations (domain 2), personal protective equipment (PPE) use (domain 3), and administrative aspects (domain 4-6) of infection control. The appraisal tool performed well across the six domains, and the inter-rater agreement was excellent for the 40 guidelines. All included guidelines performed relatively better in domains 1–3 than in domains 4–6, and this was more evident in guidelines originating from lower income countries. Conclusion The guideline appraisal tool was robust and easy to use. Engineering recommendations aspects of infection control, administrative measures that promote optimal PPE use, and HCW wellbeing were generally lacking in assessed guidelines. This tool may enable health systems to adopt high-quality HCW infection control guidelines during the severe acute respiratory syndrome coronavirus 2 pandemic and may also provide a framework for future guideline development.

Hydrogen is gaining increased attention from industries and policymakers in China. However, most of the current demonstration projects in the country have relied on conventional energy sources, including industrial byproduct hydrogen and grey hydrogen produced from fossil fuels. Moreover, strategies and policy frameworks leading to a shift to green or low-carbon hydrogen have neither been explored in-depth nor been identified clearly in the context of China. This study aims at bridging such gaps. Roadmapping techniques enhanced by the Delphi method and SWOT analysis are used to survey hydrogen energy experts from government bodies, industries, and academia to achieve basic agreement on strategically enabling large-scale green hydrogen demonstrations followed by commercialisation in China. The outcome of two rounds of surveys showed that experts' opinions converged on a strategic roadmap with three stages of development. The corresponding policies needed in each stage are evaluated and selected to form a systemic framework.

Background In the strained actual economic context, all clinical pharmacy activities cannot be achieved for all patients of all care pathways. So finding a way to prioritize moments and patients needing those activities is essential. This is the challenge of the “5P project” (Patient personalized clinical pharmacy program integrated into care pathway). Objective To present adverse event (AE) risk management approach applied to develop clinical pharmacy programs integrated into care pathway, using two methods. Method Used as a priori AE risk management approach, the Delphi method and inductive approach analysis of semi-directed interviews were realized from April 1st to October 3rd, 2019, respectively in orthogeriatric (OG) and pediatric kidney transplantation (PKT) care pathways. Complementarily to bibliographic research, participants were medical and paramedical healthcare providers involved in the concerned care pathway. They have been interrogated regarding AE risks to identify the clinical pharmacy activities required, the patients who need them, and the appropriate steps of the care pathway. Results The Delphi method for OG care pathway has revealed: 1/. Patients were prioritized by the presence of at least 2 among the following 4 criteria: age ≥90 years old, cardiovascular diseases, prescribed potentially inappropriate medication for elderly patients, obesity or diabetes; priority steps were the post-operative and rehabilitation care steps. 2/. Prescription reviews, medication reconciliation and targeted pharmaceutical informative interview about oral anticoagulants were required. Nine semi-directed interviews used for PKT care pathway has revealed: 1/. Clinical pharmacy activities were carried out for all patients. Priority steps were pre-transplantation, immediate post-operative, and post-transplantation. 2/. Prescription reviews and educative interviews were required. Conclusions The two presented methods can be used to both develop patient prioritization and targeting steps for clinical pharmacy activities, and integrate it into care pathway. Today, those two developed programs have been executed in our teaching hospital.

Background The practice standards of specialist areas of nursing need to be distinctive and reflect contemporary practice. In the absence of intellectual and developmental disability content in curriculum design at both undergraduate and postgraduate levels, nurses practising in this specialty area need a clear set of standards that guide their practice. Aim To redevelop a contemporary set of practice standards by combining findings from a three-year research project with the Delphi technique to determine consensus. Methods The Delphi technique was applied to a draft set of eight standards that were developed based on research generated by the project. Data were generated through two Delphi rounds conducted via Qualtrics© online surveys. Data analysis consisted of descriptive statistics for percentage agreement, and content analysis for qualitative data. Findings Response rate was 72% for round one and 77% for round two. Consensus was reached for each of the eight standards in round one. Consensus was reached for the schema, following round two. Discussion The revised set of specialty standards offers points of distinction that sets them apart from other practice standards by reflecting the values, knowledge and skills required to work in intellectual and developmental disability nursing. Conclusion A combination of research evidence and the Delphi technique was useful in determining a new framework for practice standards that reflected current practice. Differentiating specialty practice standards offers identity and guidance for nurses practicing in specialised areas of nursing. The revised standards are a useful resource in policy development and education design.

BACKGROUND/PURPOSE Taiwan set up disaster medical assistance teams (DMATs) after the Chi-Chi earthquake, but these teams lack unified standards. METHODS This study was divided into two phases. Phase I was a Delphi study conducted in 2019 with 26 experts who were invited to establish Taiwan's DMAT standards by modifying the World Health Organization Emergency Medical Team (WHO EMT) type I fixed standards. Phase II was a cross-sectional study conducted in 2020. A questionnaire was used to evaluate the disaster preparedness of DMATs by standards set in phase I. RESULTS In phase I, Taiwan's DMAT standards were established after three rounds of Delphi consensus, with a response rate of 88.5%. The major departures from the WHO EMT standards were the exclusion of obstetric care, mental health, rehabilitation, and laboratory and blood transfusion standards and the addition of an ultrasound standard. During phase II, a total of 32 teams were invited, and the response rate was 96.9%. The overall standard achievement rate was 56.9%, and the three lowest achievement rates corresponded to sanitation (22.6%), medical malpractice insurance (25.8%), and pharmacy and drug supply (25.8%). The national DMATs, official DMATs, DMATs funded by government, and DMATs with ≥10 years of experience had significantly higher achievement rates for partial or overall standards. CONCLUSION Using localized standards to evaluate the disaster preparedness of each team, DMATs were found to have many shortcomings mainly due to the lack of unified government announcement standards, legal protection, and adequate financial support.

Objectives Primary healthcare will not be effective unless there is a proper referral system. In contrast, comparing the performance of healthcare systems provides an opportunity for policy makers to determine the status of the country’s healthcare system compared with their international counterparts. Therefore, we ranked the countries in terms of indicators affected by the referral system. Methods This study was conducted in 2020. In the first phase, which was to determine the indicators affected by a country’s referral system, data were collected by the Delphi method, and therefore, 13 indicators with a content validity ratio equal to or greater than 0.42 were selected. In the second phase, the data of 13 indicators selected in the first phase were extracted from the 2018 and 2019 World Health Organization reports. The weight of the indicators was calculated based on the Decision-Making Trial and Evaluation Laboratory method–based Analytic Network Process (DANP) and Shannon’s entropy, and the VIekriterijumsko KOmpromisno Rangiranje (VIKOR) method was used to rank the countries. SPSS 24 and Excel 2013 software were used for data analysis. Results Switzerland, Germany, and Sweden ranked first, second, and third, respectively. In all the 3 countries, there are no mandatory gatekeeping systems. Physicians, especially general practitioners, are the core of primary healthcare, and in all the 3 countries, there is a uniform and coherent health financing system that is either based on mandatory health insurance (Switzerland and Germany) or taxes (Sweden). India had the lowest ranking. Conclusions It seems that the study of the health system of the countries that have obtained higher rankings can indicate their efforts in establishing a gatekeeping system, family physician program, and appropriate financing system. Therefore, other countries can study successful countries and copy them as a model to improve their health system.

Setting Nonoptimized medication therapies (NOMTs) are associated with likely avoidable illnesses and mortality affecting millions of people and costing an estimated $528 billion per year in excess health spending in the United States. The coronavirus disease 2019 (COVID-19) pandemic brought into focus barriers limiting the ability of U.S. pharmacists and pharmacies to provide services that can reduce NOMTs and improve U.S. population health. Objectives This National Science Foundation Center for Health Organization Transformation study explored potential strategies that U.S. pharmacists, pharmacies, and their partners could implement to reduce NOMTs while also delivering other forms of value to U.S. populations from 2021 to 2025 (during and after the COVID-19 pandemic). Design A panel of senior leaders representing the U.S. pharmacist and pharmacy sector participated in a 4-round Delphi process to identify unmet needs, barriers, change drivers, and priority strategies for meeting those needs. Data were gathered and analyzed by public health researchers, most of whom are outside the pharmacist and pharmacy sector. Results A comprehensive set of evidence-based strategies with potential to reduce NOMTs, protect and improve population health and well-being, and strengthen the sector were identified. Four transformational strategies were recommended: comprehensive payment and practice transformation, strengthening pharmacy data interoperability infrastructure, development of unifying measurement and management mechanisms, and development of a more robust national research infrastructure. Strengthening health equity was a cross-cutting strategy affecting all areas. Conclusion The results may be of interest to policy makers, pharmacists, pharmacies, physicians, nurses and other clinicians, pharmaceutical firms, plan sponsors, plans, health systems, clinics, aging care, digital technology companies, and others interested in optimizing outcomes from medications and related therapies for U.S. populations.

Background Maternal satisfaction with maternity care is an important indicator of quality maternity services. Continuity of midwifery models of care are increasing in Australia and while several instruments have been developed to measure satisfaction with maternity care most of these have not been validated and there are none that are appropriate to continuity of midwifery maternity care models. Aim To develop a questionnaire to measure women’s satisfaction with maternity services provided in a continuity of midwifery care service model. Methods A modified Delphi technique was used. A heterogenous panel of eight experts provided feedback over four rounds. The starting point for the questionnaire was informed by two systematic literature reviews focusing on available instruments for measuring maternal satisfaction with maternity care and what women value continuity of midwifery models of care. Findings The Continuity of Midwifery Care Satisfaction Survey (COMcareSS) was developed after four rounds of feedback with the expert panel. The survey comprises nine domains and fifty-nine questions. The domains include demographics, maternity care outcomes, facilities, the midwife/woman relationship, building capacity-empowerment, decision making and involvement, personalised care, advice care and support and general. Conclusions Consumer satisfaction is an important indicator of quality care. This is the first instrument to be developed that is appropriate to continuity of midwifery models of care. The important next step is to pilot test the instrument to establish its validity and reliability.

There is currently a degree of divergence among the main clinical practice guidelines on the management of risk factors for peripheral arterial disease (PAD). This project aims to gain understanding of the management of PAD risk factors in clinical practice and to reach a multidisciplinary consensus on the strategies to be followed in order to optimize its identification, treatment, and follow-up.A multidisciplinary consensus following the Delphi methodology.Professionals (n = 130) with extensive experience in PAD participated in this consultation. The results suggest that in order to optimize the control of risk factors, efforts should be aimed at: (1) promoting the involvement and awareness of all specialists in the identification of and screening for the disease; (2) guaranteeing the possibility of evaluating the ankle-brachial index (ABI) in all the medical specialties involved; (3) promoting strategies for patients to quit smoking through the use of drugs, programs, or referrals to specialized units; (4) promoting an appropriate Mediterranean-based diet and the prescription of daily exercise; (5) raising awareness of the importance of ensuring LDL cholesterol values below 70 mg/dL, especially in symptomatic but also in asymptomatic patients (55 mg/dL following the publication of the ESC/EAS guide); (6) recommending the use of antiplatelet therapy in asymptomatic patients with diabetes mellitus (DM) and/or a pathological ABI; and (7) protocolizing the annual evaluation of ABI in high-risk patients.This document presents the 22 agreed-upon strategies which are intended to help professionals optimize multidisciplinary management of PAD risk factors.

Background: The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs. Objective: To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program. Methods: 69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis. Results: Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition. Conclusion: Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.

The Delphi Technique is a group judgement method which is typically used to reach agreement from a group of people with expertise in a particular area. It is an iterative process where panel members complete questionnaires over several rounds, often rating their agreement/disagreement against a statement, with changes made in later rounds based on the feedback received. It has been used widely in pharmacy-related studies relevant to education, research and practice. This paper provides a critical analysis of the various design choices which researchers may consider when planning a Delphi namely the panel of participants, the use of the Likert scale, the effect of feedback, what constitutes consensus and the number of rounds. It also gives an overview of the development and origins of the Delphi, and discusses the advantages and disadvantages of the technique. Advantages include that the Delphi can be conducted with panel members in different geographical locations in their own time, however the technique can therefore take longer to conduct and lacks face-to-face discussion. Patient experts may be less comfortable participating in a relatively complex survey, however the anonymous nature of the process can be more inclusive in allowing participants to feedback candidly. This paper shows the importance of careful planning of the design choices to ensure the reliability and validity of the Delphi.

Consensus research methods are used in health services research to generate evidence through systematic means of measuring collective agreement and developing consensus from experts of a subject matter. Delphi technique is the most commonly reported consensus research method and is a structured, multistage interaction method to determine consensus using repetitive administration of anonymous questionnaires across two or three rounds. The Delphi technique is increasingly being used in pharmacy practice research. Despite its wide use in the development of statements of policies, guidelines, and performance indicators, there is lack of standardized guidelines and criteria to support the Delphi technique study design, conduct, and reporting, leading to inconsistent approaches and methodological difficulties among researchers. In this themed article, we provide the reader with a collation of best practices and highlight key methodological issues and areas of uncertainty of the Delphi method, especially as it pertains to pharmacy practice research.

[Resumen] Introducción y objetivos. La insuficiencia cardiaca (IC) supone un reto para los sistemas sanitarios que se puede responder a través del desarrollo de modelos integrales de atención. Un grupo multidisciplinar de expertos reflexionó sobre los factores clave para avanzar en el desarrollo de este tipo de modelos, planteando una hoja de ruta dirigida a todos los agentes (administraciones, gestores y profesionales sanitarios). Métodos. Se conformó un panel Delphi multidisciplinar integrado por un comité asesor de 15 expertos y un panel adicional de 31 expertos. A través de una revisión bibliográfica sistemática y entrevistas individuales semiestructuradas se realizó un diagnóstico e identificación de retos y áreas de mejora a lo largo del proceso asistencial. El panel Delphi consensuó y priorizó los factores clave con la metodología Delphi Rand/UCLA, valorando su adecuación y necesidad. Resultados. Tras 2 rondas de valoración Delphi se consensuó una propuesta de 7 retos y 75 factores clave para el desarrollo de modelos integrados para la IC. Los 25 factores clave considerados altamente prioritarios se relacionan con la necesidad de una mayor coordinación y planificación a nivel de gestión sanitaria, el abordaje integral durante la hospitalización y la implantación de medidas de continuidad y coordinación asistencial, garantizando que se cubren las necesidades específicas de diferentes perfiles de pacientes. Conclusiones. La propuesta y priorización de acciones para avanzar en modelos de atención integral a la IC debe surgir de reflexiones multidisciplinares y multinivel que incluyan la visión de los pacientes y cuidadores. [Abstract] Introduction and objectives. Heart failure (HF) is a challenge for health systems that can be responded through the development of comprehensive care models. A multidisciplinary group of experts reflected on the key factors that could facilitate the development of this type of models, proposing a roadmap aimed at all agents (politicians, managers, administrators, and health professional). Methods. A multidisciplinary Delphi panel was formed, made up of an advisory committee of 15 experts and an additional panel of 31 experts. After a systematic bibliographic review and semi-structured individual interviews, a diagnosis and identification of challenges and areas for improvement were made throughout the healthcare process. The Delphi panel agreed and prioritized the key factors applying Delphi Rand/UCLA methodology, assessing their appropriateness and need. Results. After 2 rounds of Delphi assessment, a proposal of 7 challenges and 75 key factors was agreed upon for the development of integrated models for HF. The 25 key factors considered high priority are related to the need for greater coordination and planning at the health management level, the comprehensive approach during hospitalization and the implementation of measures of continuity and care coordination, ensuring that the specific needs of different patient profiles. Conclusions. The proposal and prioritization of actions to advance in models of comprehensive care for HF must arise from multidisciplinary and multilevel reflections that include the vision of patients and caregivers. El proyecto MAIC ha sido financiado por Boehringer Ingelheim España

Background Over the last decade, preoperative anemia has become recognized as a clinical condition in need of management. Although the etiology of preoperative anemia can be multifactorial, two-thirds of anemic elective surgical patients have iron deficiency anemia. At the same time, one-third of non-anemic elective surgical patients are also iron deficient. Methods Modified-RAND Delphi methodology was employed to identify areas of consensus among an expert panel regarding the management of iron deficiency in patients undergoing cardiac surgery. A list of statements was sent to panel members to respond to using a five-point Likert Scale. All panel members subsequently attended a face-to-face meeting. The initial survey was presented and discussed, and panel members responded to each statement on the Likert scale again. Based on the second survey, the panel came to a consensus on recommendations. Results The panel recommended all patients undergoing cardiac surgery be evaluated for iron deficiency, whether or not anemia is present. Evaluation should include iron studies and reticulocyte hemoglobin content. If iron deficiency is present, with or without anemia, patients should receive parenteral iron. Erythropoietin stimulating agents may be appropriate for some patients. Conclusions Consensus of an expert panel resulted in a standardized approach to diagnosing and managing iron deficiency in patients undergoing cardiac surgery.

Recently coal supply chain has obvious benefits regarding stability, economy and safety. But issues increased in the coal supply chain management (CSM) process greatly impacted organizational performance. Therefore, one of the key problems in CSM is identifying and prioritizing the various risks and finding suitable solutions for encountering them at the time of risk occurrence. The objective of the paper is to determine the most influential risk in the context of the South Indian Thermal power plant. For this purpose, a multi-criteria decision-making (MCDM) based stepwise weight assessment ratio analysis (SWARA) method has been used to investigate the CSM risks. Based on the Delphi method, thirteen CSM risks were identified. As per the method SWARA, the relative weight of each risk was computed. The findings indicated that power plant-specific fuel consumption, the geographical location of plants from mines, and the quality of coal are the most influential ones. In addition to this, this paper provides some useful implications for managers in the industry regarding organizational performance implementation.

Background Effects of the institutional macrocosm on general surgery resident wellbeing have not been well studied. We sought to identify organizational factors that impact resident wellness and burnout. Methods Using a modified Delphi technique, an open-ended survey and two subsequent iterations were distributed to wellness stakeholders at two institutions to identify and stratify institutional factors in six burnout domains. Results Response rates for each survey round were 29/106 (27%), 30/46 (65%) and 21/30 (70%). Top factors identified in each domain were: • Workload: hours (60% respondents), advanced practice providers (53%) • Control: autonomy (77%), scheduling blocks/changes (43%) • Rewards: compensation (93%), vacation (83%) • Community: peer support (66%) and mentorship programs (59%) • Fairness: budget allocation (48%), resident union (48%) • Values: mentorship program (43%), institution type (40%) Conclusion A modified Delphi technique prioritized institutional wellness and burnout factors. Top factors identified were compensation, vacation time, and autonomy. These results can direct future scholarship of barriers/facilitators of resident wellbeing.

Assessing the success of climate change adaptation initiatives and expenditures requires consideration of multiple complex dimensions that interact across time and space—a task that is difficult and sometimes controversial. These challenges are exacerbated in conservation contexts where there are no clear and accepted definitions, goals, strategies, and evaluation criteria for adaptation. Using a Delphi expert elicitation (n = 18) involving successive semi-structured interview and survey phases, we address this gap by developing a concise yet comprehensive set of criteria to evaluate the success of adaptation projects. Through this process we identified 16 evaluation criteria organized into four categories: (1) use of information, (2) project management, (3) ecological and social outcomes, and (4) advancing the field of adaptation. We then trialed these criteria using an online survey of adaptation practitioners (n = 47), including to assess the relative importance of the various criteria for evaluating climate adaptation projects as compared with the views of experts involved in the Delphi survey. Results highlight a potential disconnect between what is considered important in theory (as perceived by experts) and in practice (as perceived by practitioners). Finally, we discuss potential use of the evaluation criteria.

Objectives Reward and recognition of surgical education as an academic activity remains a highly variable process between institutions. The goal of this study is to provide expert consensus definition of an academic surgical educator, with focus on criteria for academic promotion. Study Design and Setting Following IRB approval, a Web-based modified Delphi process was used to generate prioritized academic promotion criteria for surgical educators. Participants and setting Participants were recruited nationally from a pool of senior academic surgeons who are members of the Society of University Surgeons and the Society of Surgical Chairs. Results Following a three-round modified Delphi process, the top domains of educational activity for promotion to associate professor and professor were scholarship, teaching, and administration; mentorship was also a priority category for promotion to professor. The top three activities described for promotion to Associate Professor were active participation in conferences/ departmental educational activities for medical students and residents; educational portfolio demonstrating commitment to activities as an educator; and clinical teaching excellence at their home institution. The three activities most highly scored items for promotion to Professor were mentorship of junior surgical educators; active participation in conferences/ departmental educational activities for medical students and residents; and a record of teaching excellence at the medical student and resident levels. Conclusions These findings demonstrate a progression from teacher to scholar to leader across a surgical educator's career, with each level incorporating and building upon the prior activities. Identification of categories and criteria may meaningfully inform best practices to be incorporated into the career development and promotion processes for surgeons on an educator academic pathway.

Sugar industry plays an important role in Indian economy and also faced challenges and opportunities in sustainability process. In the modest business scenario, evaluating sustainability risks is a major task for any industry. The process of evaluating the sustainability risks includes incorporating various information sources, which are normally incomplete, subjective and uncertain in nature. Therefore, this research work proposes a theoretical framework to develop the effective sustainability. Risk factors are identified from literatures and experts opinions. Additionally, Delphi method is used to finalize the risk factors based upon the average of industrial expert’s comments. After recognizing the sustainability risks, Analytical Hierarch Process (AHP) is used to analyse, prioritize and ranking the risks. In this research work, case study is conducted in well-known south Indian sugar industry to verify the proposed framework. From the research findings, overuse of water (S1) is the most dominant one in the sustainability process. Additionally, Best Worst Method (BWM) is used for verifying the AHP results. The research outcomes will support practitioners, researchers and managers by giving valuable insights on risks and potential ways to implementing sustainability.

Background During the COVID-19 pandemic, the management of hospital infection became even more crucial. Therefore, it is urgent to develop a competency model for the healthcare practitioners to adhere to combating public health emergencies. Aim This study was undertaken to determine the practitioners' competence in the hospital infection prevention and control measures that are significant for their competence development. Method Based on the literature review, the key informant interviews, the Delphi method, and the questionnaire survey, a theoretical framework was developed. These items were evaluated based on the response rate, maximum score, minimum score, and mean score. Factor analyses, both exploratory and confirmatory, were used to determine the structure of the competence model. Results The effective response rate on the questionnaires was 88.29%, and Cronbach's α-coefficient of the scale was 0.964. Factor analysis revealed a KMO of 0.945. The Bartlett's test gave an χ2 of 10523.439 (df = 435; p < 0.001). After exploratory factor analysis, the 5-factor model was retained, 4 items were deleted, and a 5-dimensional, 26-item scale was obtained. The new structure's confirmatory factor analysis revealed a high goodness of fit (CFI = 0.921; TLI = 0.911; SRMR = 0.053; and RMSEA = 0.044). Conclusion The proposed scale is a useful tool to assess the competence of hospital infection prevention and control practitioners, which can help hospitals to improve their work of infection prevention and control., HIPCPs: hospital infection prevention and control practitioners.

Topical and systemic retinoids are often used long-term in the treatment of ichthyoses and other disorders of cornification. The Pediatric Dermatology Research Alliance (PeDRA) Use of Retinoids in Ichthyosis Work Group was formed to address the numerous clinical concerns with use of these medications in children and adolescents and to establish best practices regarding the use of retinoids. Consensus was achieved using the Delphi process with recommendations based on the best available evidence and expert opinion. An executive summary of the results is presented herein.

Background & aims: An estimated 38% of adults worldwide have non-alcoholic fatty liver disease (NAFLD). From individual impacts to widespread public health and economic consequences, the implications of this disease are profound. This study aimed to develop an aligned, prioritised fatty liver disease research agenda for the global health community. Methods: Nine co-chairs drafted initial research priorities, subsequently reviewed by 40 core authors and debated during a three-day in-person meeting. Following a Delphi methodology, over two rounds, a large panel (R1 n = 344, R2 n = 288) reviewed the priorities, via Qualtrics XM, indicating agreement using a four-point Likert-scale and providing written feedback. The core group revised the draft priorities between rounds. In R2, panellists also ranked the priorities within six domains: epidemiology, models of care, treatment and care, education and awareness, patient and community perspectives, and leadership and public health policy. Results: The consensus-built fatty liver disease research agenda encompasses 28 priorities. The mean percentage of 'agree' responses increased from 78.3 in R1 to 81.1 in R2. Five priorities received unanimous combined agreement ('agree' + 'somewhat agree'); the remaining 23 priorities had >90% combined agreement. While all but one of the priorities exhibited at least a super-majority of agreement (>66.7% 'agree'), 13 priorities had 90% combined agreement. Conclusions: Adopting this multidisciplinary consensus-built research priorities agenda can deliver a step-change in addressing fatty liver disease, mitigating against its individual and societal harms and proactively altering its natural history through prevention, identification, treatment, and care. This agenda should catalyse the global health community's efforts to advance and accelerate responses to this widespread and fast-growing public health threat. Impact and implications: An estimated 38% of adults and 13% of children and adolescents worldwide have fatty liver disease, making it the most prevalent liver disease in history. Despite substantial scientific progress in the past three decades, the burden continues to grow, with an urgent need to advance understanding of how to prevent, manage, and treat the disease. Through a global consensus process, a multidisciplinary group agreed on 28 research priorities covering a broad range of themes, from disease burden, treatment, and health system responses to awareness and policy. The findings have relevance for clinical and non-clinical researchers as well as funders working on fatty liver disease and non-communicable diseases more broadly, setting out a prioritised, ranked research agenda for turning the tide on this fast-growing public health threat.

Background Acne is a chronic disease with a varying presentation that requires long-term management. Despite this, the clinical guidelines for acne offer limited guidance to facilitate personalized or longitudinal management of patients. Objectives To generate recommendations to support comprehensive, personalized, long-term patient management that address all presentations of acne and its current and potential future burden. Methods The Personalising Acne: Consensus of Experts panel consisted of 13 dermatologists who used a modified Delphi approach to reach consensus on statements related to longitudinal acne management. The consensus was defined as ≥75% voting "agree" or "strongly agree." All voting was electronic and blinded. Results Key management domains, consisting of distinct considerations, points to discuss with patients, and "pivot points" were identified and incorporated into the Personalised Acne Care Pathway. Long-term treatment goals and expectations and risk of (or fears about) sequelae are highlighted as particularly important to discuss frequently with patients. Limitations Recommendations are based on expert opinion, which could potentially differ from patients' perspectives. Regional variations in health care systems may not have been captured. Conclusions The Personalised Acne Care Pathway provides practical recommendations to facilitate the longitudinal management of acne, which can be used by health care professionals to optimize and personalize care throughout the patient journey.

The purpose of this article is to share gaps in knowledge and research related to pandemic management identified by nurse leaders during the COVID-19 pandemic. As part of a larger Delphi study, nurse leaders responded to an open-ended question about gaps in research they saw as important following the pandemic. Responses were analyzed using directed content analysis. Results are presented as 4 supercategories: Organizational leadership preparedness, adaptive leadership in crisis, innovations in care delivery, and health, well-being, and resilience.

There are differences in state laws and regulations that restrict nurse practitioners (NPs) from performing certain patient care functions, such as signature recognition. In California, it has been a slow, incremental process for NPs to gain the ability to sign and/or certify forms that facilitate patient care. States are moving forward to ensure NP signatures are recognized either by updating language in their state laws and allowing NPs to sign specific forms or adopting statutes that provide NPs with global signature recognition (GSR). A policy Delphi approach was used to guide the analysis of GSR for NPs in California.

Background Internationally, nurses are gaining recognition for their contributions to public health and global health initiatives, however, their contributions to surveillance and the detection of new and emerging infectious disease, which is an important element of global health security, remain largely unknown. Purpose The purpose of this study was to investigate the perceptions of nurse experts related to the current and optimal roles of nurses in surveillance of new and emerging infectious diseases. Additionally, this study aimed to identify the skills needed by nurses in all practice settings for optimal performance of surveillance and to identify barriers to achieving optimal performance of surveillance. Methods A three-round Delphi study was conducted. Nurse experts participated in Round 1 interviews followed by ranking current and optimal role, skill, and barrier statements in Rounds 2 and 3. Findings Findings revealed four current roles and 13 optimal roles for nurses in surveillance, 13 skills needed to perform surveillance activities, and seven barriers to optimal performance of surveillance activities by nurses. Disucssion Results of this study are intended to inform nursing practice and education in the U.S., and to provide guidance on the role of nurses in surveillance of new and emerging infectious disease as part of the Global Health Security Agenda.

Objective To examine how nurses describe caring for women and families in specialized fetal diagnosis and treatment settings. Design We used narrative inquiry. Setting A secure online survey platform. Participants We recruited 26 nurses from the Fetal Therapy Nurse Network as a subsample from a prior Delphi study on the essential structures, processes, outcomes, and challenges of nursing practice in the emerging field of fetal diagnosis and treatment. Methods We used narrative inquiry and Clandinin’s three-dimensional space narrative analysis to interpret the stories provided by participants to illustrate their practice and the relationship between their practice and care quality and health outcomes. Results Participants described three primary types of fetal diagnoses and management scenarios: prenatal intervention (maternal–fetal surgery to treat a fetal anomaly), postnatal intervention (neonatal surgery), and perinatal palliative care (continuation of a pregnancy after a life-limiting fetal diagnosis). We identified three overarching themes related to nursing processes: A Sounding Board: Counseling the Pregnant Woman and Family, A Care Coordinator: Orchestrating a Complex Journey, and A Constant Presence: Being With the Pregnant Woman and Family. We also identified specific outcomes related to nursing care. Conclusion We used narrative inquiry to expand on prior research and advance the conceptualization of a model of nursing practice in fetal diagnosis and treatment settings. Our results provide a basis to begin to test theories that connect nursing practice to care quality and outcomes in clinical practice settings. To comprehensively evaluate and enhance care as it evolves and expands, the immediate and long-term effects of nursing practice must be identified.

Objective A national robotic surgery curriculum is still developing for general surgery residents as robotic surgery becomes increasingly accessible. One general surgery residency program utilized a Delphi process to optimize a robotic surgery curriculum and to determine key factors that might affect robotic proficiency and intraoperative independence. Design Delphi methodology was used to gain consensus amongst robotic surgery faculty and trainees. Consensus was defined as agreement of 66.7% or above in factors that would allow a resident to independently operate in a robotic case. A panel of diverse representatives proposed factors that might affect resident robotic learning and operative experience. In a subsequent round, questions were sent through an anonymous online survey for respondents to identify factors that affect resident robotic independence. Respondents were also given the ability to write in pertinent factors. Setting This study was conducted from July 2020 to September 2020 via anonymous web-based questionnaires for education researchers, faculty members, and residents of a university-affiliated independent general surgery residency program. Participants The initial panel consisted of a robotic surgeon, a 2020 graduate, a 2019 graduate and/or robotic fellow, a research resident, and a current resident. The subsequent survey was completed by 8 faculty members, 6 recent graduates, and 15 current residents within the general surgery residency program. Results Proposed items fell into 3 categories: institutional resources, individual qualities, and curricular elements. Consensus within groups was achieved in the following items: dual robotic console models, robotic-focused faculty, resident interest, PGY level, and resident time spent on a simulator. Conclusions This Delphi exercise has informed this general surgery residency program in the development of a robotic surgery curriculum, through contribution from multiple stakeholders. While curricular elements for baseline robotic knowledge are necessary, institutional resources, deliberate practice, resident entrustment and faculty teaching proficiency warrant further study.

Objective To obtain expert consensus on indicators of quality rehabilitation services for individuals with limited English proficiency (LEP). Design Three-round Delphi study. Setting Delphi survey conducted online with 30 experts. Most experts worked in adult physical rehabilitation settings and were from Illinois (n=16), with remaining participants from eight other US states or Canadian provinces. Participants Experts had a minimum of two publications on healthcare services for patients with LEP and/or a minimum of five years clinical experience in physical rehabilitation. Of 43 experts (11 researchers, 32 clinicians) emailed the Round One survey, 30 returned complete responses (70% response rate). Of those, 25 completed Round Two, and 24 completed Round Three. Of Round One participants, most (n =21) identified their primary professional activity as clinical, whereas the others worked in research (n =5) or education (n =4). Twenty-four were female. Median age was 43 (range 27-67). Disciplines included occupational therapy (n =14), physical therapy (n =13), psychology (n=1), nursing (n=1), and medicine (n=1). Interventions Not applicable. Main outcome measures Indicators rated on a seven-point Likert scale for importance and feasibility. Interquartile range (IQR) and 95% confidence intervals calculated for importance and feasibility ratings. Indicators with an IQR Results Round One responses were categorized into 15 structural, 13 process and 18 outcome indicators. All 15 structural indicators reached consensus for importance; eight were rated as feasible. All 13 process indicators reached consensus, of which eight were deemed feasible. Sixteen outcome indicators reached consensus, of which seven were deemed feasible. Conclusions This Delphi study identified structural, process, and outcome indicators that can inform delivery and assessment of quality rehabilitation services for individuals with limited English proficiency. Future research should operationalize and measure these quality indicators in clinical practice.

Objective To develop an international definition for hyperemesis gravidarum to assist in clinical diagnosis and harmonize hyperemesis gravidarum definition for study populations. Study design: A mixed-methods approach was used to identify potential hyperemesis gravidarum definition criteria (i.e. systematic review, semi-structured interviews and closed group sessions with patients and Project Steering Committee input). To reach consensus on the definition we used a web-based Delphi survey with two rounds, followed by a face-to-face consensus development meeting, held in Windsor UK, and a web-based consultation round, in which the provisional hyperemesis gravidarum definition was fed back to the stakeholders. Four stakeholder groups were identified 1) researchers; 2) women with lived experience of hyperemesis gravidarum and their families; 3) obstetric health professionals (obstetricians, gynecologists, midwives); and 4) other health professionals involved in care for women with hyperemesis gravidarum (general practitioners, dieticians, nurses). To reflect the opinions of the international community, stakeholders from countries in all global regions were invited to participate. Results Twenty-one identified potential criteria entered the Delphi survey. Of the 277 stakeholders invited, 178 completed round one, and 125 (70%) also completed round two. Twenty stakeholders attended the consensus development meeting, representing all stakeholder groups. The consultation round was completed by 96 (54%) stakeholders, of which 92% agreed with the definition as presented. The consensus definition for hyperemesis gravidarum consisted of: start of symptoms in early pregnancy (before 16 weeks gestational age); nausea and vomiting, at least one of which severe; inability to eat and/or drink normally; strongly limits daily living activities. Signs of dehydration were deemed contributory for the definition for hyperemesis gravidarum. Conclusions The proposed definition for hyperemesis gravidarum will help clinical studies to achieve more uniformity, and ultimately increasing the value of evidence to inform patient care.

Background Postvention aims to implement services adapted to the needs of a population that may be vulnerable after suicide. While a plethora of postvention programs exist, they are generally based less on solid evidence than on the judgment of health professionals. Using the Delphi method, an Australian study obtained a consensus among experts as to which postvention actions are to be engineered in a postvention program. Since no similar study has been carried out for programs in French-speaking countries, it seemed important to reproduce the same type of study and to compare the respective results. The present study is aimed at establishing a French inventory of postvention actions and at achieving a consensus among experts as to the actions to be included in a postvention program. Methods A systematic review of the scientific literature (PRISMA method) and the gray literature (documentation on the WEB) made it possible to identify the different actions that have been included in various postvention programs. Using the DELPHI method, experts endeavored to assess their relevance. Results An inventory of 190 postvention actions was established and they were classified according to a sequential axis (pre-event, at the time of the event, and post-event), according to type of action (environment-centered or people-centered). The experts identified 128 actions to be included in a postvention program. Conclusion Convergence was observed among the experts, as they identified the practices to be encouraged following a suicide. When comparing the results in French-speaking countries to the 548 actions selected in the Australian study, we observe similarities between the two studies regarding types of postvention actions. This study provides an update for health professionals on the most relevant practices to be included in a postvention program.

Background Making trials more patient-centred improves recruitment and retention, patient satisfaction and makes research accessible to a more representative population. We aimed to understand the factors that influence participation and engagement in clinical trials in cystic fibrosis (CF) trials to guide the rational design and delivery of patient-centred trials. Methods We used a Delphi process, supported by extensive literature review and 3 workshops, to determine which factors stakeholders think exert significant influence in participation and engagement in CF trials. Panellists were recruited from across the UK and the study was administered online. Results We had representation from 19 CF centres; 28 people with CF (pwCF), 26 parents and 30 healthcare professionals (HCPs). Panels were presented with a shortlist of 104 factors and asked which they thought influence participation and engagement in CF trials. After 3 iterations, 43 statements met consensus for pwCF, 48 for the parents and 69 for the HCPs. Conclusions We identified many targets to make trials more patient-centred. Whilst some require an overhaul of trial delivery, many are relatively easy to implement. We outline a list of ‘dos and don'ts’ for sponsors and research teams including: focus on good communication; recognise that lack of time is the greatest barrier to trial participation so minimise the frequency and length of visits; help participants fit trials around busy lives; remember trial participation can be a major life-event and support participants accordingly; and don't underestimate the impact of simple strategies e.g. on-site access to Wifi and cups of tea.

Objective To develop a minimum data set, known as a core outcome set, for future abortion randomized controlled trials. Study design We extracted outcomes from quantitative and qualitative systematic reviews of abortion studies to assess using a modified Delphi method. Via email, we invited researchers, clinicians, patients, and healthcare organization representatives with expertise in abortion to rate the importance of the outcomes on a 9-point Likert scale. After 2 rounds, we used descriptive analyses to determine which outcomes met the predefined consensus criteria. We finalized the core outcome set during a series of consensus development meetings. Results We entered 42 outcomes, organized in 15 domains, into the Delphi survey. Two-hundred eighteen of 251 invitees (87%) provided responses (203 complete responses) for round 1 and 118 of 218 (42%) completed round2. Sixteen experts participated in the development meetings. The final outcome set includes 15 outcomes: 10 outcomes apply to all abortion trials (successful abortion, ongoing pregnancy, death, hemorrhage, uterine infection, hospitalization, surgical intervention, pain, gastrointestinal symptoms, and patients’ experience of abortion); 2 outcomes apply to only surgical abortion trials (uterine perforation and cervical injury), one applies only to medical abortion trials (uterine rupture); and 2 apply to trials evaluating abortions with anesthesia (over-sedation/respiratory depression and local anesthetic systemic toxicity). Conclusion Using robust consensus science methods we have developed a core outcome set for future abortion research. Implications Standardized outcomes in abortion research could decrease heterogeneity among trials and improve the quality of systematic reviews and clinical guidelines. Researchers should select, collect, and report these core outcomes in future abortion trials. Journal editors should advocate for core outcome set reporting.

Background Nursing education often employs simulation-based education to prepare for clinical practice. However, despite its perceived importance, there is no common practice for its integration into different nursing curricula. This study aimed to describe and compare the levels of implementation of simulation-based education in nursing curricula across different countries. Methods A quantitative and qualitative exploratory study was conducted in 2019 using a questionnaire developed using the Delphi technique. Eight European member institutions participated in this exploratory study. Qualitative data were hand-coded and analyzed using descriptive analysis. Results Differences were found regarding (a) simulation in nursing programs, (b) the simulation environment, and (c) expert opinions. There exists a wide range of simulation-based education accreditation systems, and the absence of regulatory standards to replace clinical hours in the curriculum is a challenge for international exchange programs. Conclusions Universities should invest in and guarantee high-quality research to evaluate national and international initiatives and contribute to simulation-based education.

The management and control of waste electrical and electronic equipment have been among the most critical challenges in recent decades. However, the existing electrical and electronic equipment consumption patterns lead to negative consequences for the environment and social and economic aspects. On the other hand, social media has demonstrated itself as an important data source to extract large amounts of information from consumers’ opinions. Therefore, an integrated approach of quantitative and qualitative methods (based on Twitter data and analysis of the literature followed by the Delphi method and the Analytic Hierarchy Process is adopted to analyze consumers’ participation in electronic waste recycling schemes, from the standpoint of sustainable development, in developed and developing countries. Considering the three pillars of “sustainable development”, the findings reveal that in developing countries, the “economic” pillar is of the highest, and the “environmental” aspect is of the least importance, and the “social” is somewhere in between. However, in developed countries, due to higher welfare, the priorities of the dimensions above are different wherein the “environmental” and the “social” pillars are of the higher importance, and the “economic” comes last. Therefore, governments and high-level policy-makers could apply the research findings to develop long-term strategies.

The importance of patient involvement in guideline development is internationally recognised, yet there is a lack of clear methodology for integrating patient preferences and values in guidelines and a need to identify the optimum stages for involving patients in guideline production. European Association of Urology (EAU) guidelines have international reach, a rigorous guideline production process, an established patient information section, and existing links with European cancer patient organisations. This makes the EAU the ideal setting to test a framework for patient involvement in guideline development for genitourinary cancers. The EVOLVE study is a unique collaboration involving a professional society, guideline panels, researchers, clinicians, and patient organisations with the aim of designing a framework for meaningful patient involvement in guideline production. Stages for considering patient preferences and values were identified via systematic review and interviews with key stakeholders, then prioritised by patients and clinicians via an international Delphi study. The final EVOLVE framework will be tested within EAU guideline panels and a strategy to assess the impact of patient involvement in guidelines will be developed. Patient summary There is increasing awareness of the need to include patient values and preferences when developing guidelines for medical practice. The EVOLVE study is designing a framework for patient involvement in guideline development. Take Home Message A framework for meaningful patient involvement in guideline development and implementation has been developed. The EVOLVE framework can help guideline developers to involve patients at the optimum stages of guideline production, which may improve the quality and relevance of guidelines.

Animal assisted interventions (AAI) refer to planned and structured interactions between humans and animals managed by a multidisciplinary team. The domestic dog (Canis familiaris) is the most involved species in this kind of programs. Even though, it is agreed worldwide that these animals should fulfil some requirements, their selection is still based on general principles and each organization gives its own interpretation. Some selection protocols were set up in the past, but they found little application in practice among professionals. Therefore, a deeper understanding of the phenomenon is needed. Our study aims to build consensus about features that make a therapy dog successful in AAI settings among Italian professionals that work in the AAI field. A three-round Delphi process was set up to get closer to this goal. All Delphi exercises were conducted using online questionnaires distributed to professionals. As a first step, respondents were asked to answer an open-ended question, asking what defining features a therapy dog should have to be eligible in most dog-assisted intervention programs, while in subsequent rounds participants rated to what extent characteristics resulting from round 1 are desirable/undesirable for a therapy dog. Thirty-three professionals responded to all rounds. The Delphi study allowed us to identify 55 defining features of a therapy dog. Among them, 16 features resulted “very desirable” with expert consensus and they all relate to dog resilience, dog emotional balance, dog willingness to collaborate with both handler and users/patients and dog communication skills. Moreover, we noticed that respondents often assign human qualities onto the animal showing anthropomorphism attitude. We concluded that a selection of therapy dog should not consider only exclusion criteria and role-playing, but their communication skills, willingness to engage, resilience and emotional balance should also be assessed. Further studies are needed to investigate the link between our results and the successful and reliable involvement of dogs in most settings of animal assisted interventions. However, our findings provided a baseline for future research that started from the professionals’ point of view with a participatory approach.

Indicadores de calidad; Transporte interhospitalario; Mejora de calidad Quality indicators; Interhospital transport; Quality improvement Indicadors de qualitat; Transport interhospitalari; Millora de la qualitat Introduction Interhospital transport is carried out by variable teams in different regions of our country, and this makes quality evaluation and benchmarking complicated. Project objective: Select and define a consensual list of quality measurement that may be used by national transport units, whether specialised or not. Methods Initial set of quality indicators was proposed by coordinators (members of representative specialised transport units in Spain). Evaluation by selected transport specialists from participating units and SECIP (Society of Paediatric Intensive Care) and SENeo (Spanish Neonatology Society) work teams. Selection of definitive indicators by Delphi method according to relevance and feasibility. Results A total of 35 quality indicators were included in the initial set. Evaluation was carried out by 22 specialists from 7 transport teams. In a first round, 4 indicators were consensually included in the definitive list. Results for the rest of metrics and comments were sent to all participants, and after a second assessment, 11 other indicators reached enough consensus. After list accomplishment, a consensual final definition for every indicator was established. Conclusions Using a consensual research method, a list of 15 common indicators was obtained, which may be used by specialised transport teams in our country, and by non-specialised clinics in charge of interhospital paediatric transport. It will allow individual performance to be assessed, as well as benchmarking, in order to find improvement opportunities and ensure the highest quality during interhospital transport. Introducción El traslado interhospitalario se realiza por equipos muy diferentes en las distintas regiones de nuestro país, lo que dificultad la comparación de su calidad asistencial. Objetivo: Seleccionar y definir una lista consensuada de indicadores de calidad aplicable a todas las unidades de transporte, especializadas o no, a nivel nacional. Material y métodos Realización de una propuesta inicial de indicadores por el comité coordinador con representantes del transporte especializado de nuestro país. Valoración del listado por especialistas en transporte de las unidades participantes y los grupos de trabajo de SECIP y SENeo. Selección de los indicadores mediante el método Delphi según su relevancia y factibilidad. Resultados El listado inicial incluyó 35 posibles indicadores. Fueron valorados por 22 especialistas pertenecientes a 7 unidades de transporte. En una primera fase se eligieron por consenso 4 indicadores, que pasaron directamente al listado definitivo. Se enviaron a los encuestados los resultados del resto de indicadores y las observaciones realizadas por los participantes, y tras ello se realizó una segunda valoración, en la que alcanzaron un consenso aceptable otros 11 indicadores. Tras la elaboración del listado, se estableció de forma consensuada la definición final de cada indicador elegido. Conclusiones Utilizando un sistema de búsqueda de consenso, definimos una lista de 15 indicadores comunes, que podría ser utilizada por las unidades especializadas de nuestro país y personal asistencial no especializado que realiza traslados pediátricos. Permitirá evaluar el rendimiento individual y comparar las diferentes unidades para encontrar oportunidades de mejora y asegurar la máxima calidad durante el transporte.

Choosing a first-line treatment to optimize long-term outcomes is a major challenge for treating patients with neovascular age-related macular degeneration (AMD). The development of several new molecules makes it critical to identify the relevant factors to consider so as to provide an optimal risk-benefit ratio when initiating a treatment in naïve patients with neovascular AMD. This paper proposes a consensus established with the Delphi method (which includes a gradation in a consensus based on an analysis of the convergence rate of answers) to provide criteria that guide the ophthalmologist's decision for treatment initiation and follow-up in neovascular AMD patients. Fourteen questions were submitted to 93 French retina experts. Thirteen (93%) of the questions reached a consensus (≥50% of answers consensual). The criteria recommended to take into account were both efficacy and onset of action of the molecules, their safety, and the ability to decrease injection frequency. The primary criterion of expected efficacy of a molecule is a combination of the gain in visual acuity and resorption of retinal fluid. With regard to safety, experts recommend tighter follow-up for molecules currently in development, and at every scheduled visit, patients should be screened to identify early any potential adverse effects such as intraocular inflammation, retinal vasculitis or vascular occlusion. Experts also emphasize the importance of the packaging of the biological, with a preference toward prefilled syringes. Injection frequency is a key factor, and the authors recommended aiming for a maximal injection interval of 12 to 16 weeks. The stability of that maximum interval is also an important factor to consider in treatment selection.; Le choix d’un traitement de 1re intention pour optimiser les résultats à long terme est un enjeu majeur de la prise en charge des patients atteints de DMLA néovasculaire. Dans un contexte actuel de molécules en développement est apparue la nécessité d’identifier les critères indispensables à prendre en compte lors de la mise en place d’un traitement chez un patient naïf atteint de DMLA néovasculaire afin de garantir un rapport bénéfice/risque optimal à long terme. Cet article propose un consensus établi selon la méthodologie de type Delphi (en intégrant une gradation dans les consensus en fonction de l’analyse du taux de convergence des réponses) qui pourrait constituer une aide pour les ophtalmologistes pour l’initiation et le suivi du traitement des patients atteints de DMLA néovasculaire. Quatorze questions ont été soumises à un panel de 93 experts rétinologues français. Treize questions (93 %) ont obtenu un consensus (≥ 50 % de réponses consensuelles). Les experts recommandent ainsi de prendre en compte en priorité l’efficacité et la rapidité d’action respectives des molécules, leur sécurité d’utilisation ainsi que leur capacité d’espacement des injections. Le critère d’efficacité attendu en priorité d’une molécule est la combinaison de l’amélioration de l’acuité visuelle et de l’assèchement des fluides. En matière de sécurité d’utilisation, les experts recommandent une surveillance supplémentaire pour les molécules actuellement en développement, et ce à toutes les visites programmées, visant à détecter précocement d’éventuels effets indésirables tels que l’inflammation intraoculaire et accordent une place importante au conditionnement de la molécule. La capacité d’espacement des injections est importante à prendre en compte et il est recommandé d’atteindre un intervalle maximal compris entre 12 et 16 semaines. La stabilité de l’intervalle maximal atteinte par les patients est également un critère de choix important.

Purpose Recovery units are typically open-plan rooms where all patients can be seen at all times; however, a new hospital has been built with 4- to 6-bed perioperative bays. The purpose of the study was to establish expert consensus regarding problems, benefits, and suggested solutions for the new design across four domains: patient safety, staff satisfaction, organizational efficiency, and maintenance of professional standards. Design We conducted a Delphi study to inform the development of a model of care for this new design. Methods A two-round Delphi study involved 71 recovery unit nurses from 13 countries. Problems, solutions, and any potential benefits of the new design were collected in round 1 and ranked in round 2. Findings The highest ranked problems were mixing conscious and unconscious patients and need for safe skilled staffing levels. The highest ranked solutions were division of patients, increased safe skilled staffing, and staff education. Conclusions Participants identified clear risks and mitigation strategies. Implementing these strategies should allow for a safer environment for both patients and staff. A model of care to ensure safety and quality in 4- to 6-bedded bay postanesthetic recovery units should address mixing of patients, staffing levels and staff education.

Reducing the amount of donor skin needed for definitive wound closure can improve outcomes in patients with severe burns. This Delphi Consensus Panel (DCP) aimed to achieve expert consensus on the percentage reduction in donor skin for autograft that constitutes a clinically meaningful benefit. A two-round DCP of fifteen US burn surgeons was conducted via a web-based survey platform. Fourteen panelists (93.3%) completed both rounds. In Round 2, consensus, defined as ≥70% agreement, was achieved for five of the seven consensus statements. All panelists agreed that a clinically meaningful reduction in the amount of donor skin required would facilitate wound management and decrease donor site morbidity experienced by patients. Furthermore, based on three treatment scenarios, consensus was achieved for a clinically meaningful reduction in the amount of donor skin required for autograft for the adult population in deep partial-thickness and full-thickness burns. Findings from this DCP indicate that an innovative cellular and/or tissue product that would reduce the needed amount of donor skin, by the identified thresholds, has the potential to improve the outcomes for patients with severe burn injuries in a meaningful way.

Study objective The first ever report of vaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynaecological was reported in 2012. There has been an exponential uptake of the number of surgeons performing such procedures worldwide with no official guidance to ensure the safe implementation of this technique into gynaecological practice due its recency. The objective of this study is to report an international consensus-based statement to help guide a basis for adopting vNOTES into clinical practice. Study design The consensus-based statement was developed amongst 39 international experts using the Delphi methodology over three successive rounds. Consensus was pre-defined as an agreement of 80% or more by the experts. Consensus sought over eight key concepts pertaining to vNOTES including patient selection, perioperative management, surgical technique, instruments, anatomy, training, registries and trials and definition of the surgical technique. Recommendations from an expert anaesthetist and urogynaecologist were also sought to give a broader perspective with respect to the implementation of vNOTES. Results Fifty nine international surgeons were invited to participate and 39 (66%) agreed to participate based on being involved in a minimum of 20 vNOTES procedures. They were from 13 countries across 5 continents (Europe, North America, South America, Australia and Asia). Participation was 100% on all three rounds. Overall, consensus was reached in 50 of the 56 questions (89%) with the remaining 6 questions where consensus was not reached pertaining to the domain of patient selection. Conclusion An international expert based vNOTES statement is presented here to help guide adoption of vNOTES based on the experience of early adopters. Consensus was achieved on most components of this consensus statement. Given the recency of this technique, until high-level evidence becomes available, this statement provides an appropriate guidance to the safe implementation of vNOTES into gynaecological practice.

Objective The International Society for Gynecologic Endoscopy (ISGE) developed this project to establish the recommendations for structured reporting of dynamic ultrasound findings, promoting on this manner the practice of standardized, comprehensive and systematic evaluation and reporting of endometriosis in pelvic structures, in correlation with the #Enzian classification. Study design A non-systematic review was done through a search on the following databases: MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Health Technology Assessment Database and Web of Science, using the medical subject heading (MeSH) term “endometriosis” (MeSH Unique ID: D004715) in combination with “diagnostic imaging” (MeSH Unique ID Q000000981) and “consensus” (MeSH Unique ID D032921). The information extracted from the articles of interest, written in English and published from inception of the above-mentioned databases until May 2021, was graded by the level of evidence using the American College of Chest Physicians (ACCP) classification system. The recommendations for a structured reporting of ultrasound findings were developed through multiple cycles of literature analysis and expert discussion following the Delphi method. Results The ISGE recommends the adoption of the terms, definitions and methods proposed by the International Deep Endometriosis Analysis (IDEA) Group for ultrasound assessment of patients with suspected or known endometriosis (grade 1C), since this is the most comprehensive and systematic concept currently available. This paper provides the ISGE structured reporting template for presenting quantitative and qualitative information upon the IDEA consensus-based sonographic assessment of the uterus, adnexa, anterior and posterior compartment. The #Enzian classification is recommended to summarize the findings in a standard fashion (grade 1B). Conclusion Mapping of pelvic endometriosis by ultrasound is accurate when trained sonographers perform the technique. Structured reporting of the lesions may improve patient counseling and treatment planning, including the organization of multidisciplinary teams and the selection of the most appropriate medical or surgical therapeutic strategy.

Adaptation pathways is a planning approach used to design flexible, long-term strategies for dealing with future uncertainty. However, emphasis on how to discuss pathways elements with stakeholders during the pathways building process is under-represented in the existing pathways literature. This paper presents a participatory methodology for building normative adaptation pathways with local stakeholders. Iterative discussions are facilitated using a Delphi study that is designed to explicitly consider institutional, and multi-actor dimensions in the formulation of future adaptive strategies. This leads to adaptation pathways that are more inclusive of local needs. This paper describes the steps for iteratively designing adaptation pathways in a multi-actor setting through a Delphi study. A pilot application of this Delphi-based adaptation pathway approach is illustrated with local actors in peri-urban Kolkata (India) for future water management. It demonstrates how this methodology offers a structured way to introduce pathways thinking to local stakeholders and helps build consensus about future preferences and adaptation options. Moreover, it stimulates discussions about normative differences across and within stakeholder groups through the underlying values that define future pathways as well as the institutional adjustments needed to successfully activate adaptations strategies over time. Future work may be directed towards to strengthening discussions around uncertainty, connecting pathways to a broader set of future scenarios, and comparing this facilitation method against other existing ones.