Indications for ordering thyroid-stimulating hormone in noncritically ill adult inpatients-A Delphi consensus recommendation.

BACKGROUND: Thyroid-stimulating hormone (TSH) is ordered commonly among inpatients, but the possibility of nonthyroidal illness syndrome challenges interpretation. OBJECTIVE: Our objective was to obtain Canadian consensus on appropriate indications for ordering TSH in the first 48 h following presentation of a noncritically ill internal medicine patient. DESIGN, SETTING AND PARTICIPANTS: Canadian endocrinologists with inpatient expertise were invited via snowball sampling to an online 3-round Delphi study. Main Outcome and Measures using a 6-point Likert scale, they rated 58 indications on appropriateness for measuring TSH in medical inpatients. These indications included clinical presentations, signs, and symptoms. Items that reached consensus and agreement (≥80% of participants selecting a rating of 5 or 6 on the Likert scale) were tabulated and dropped after each round. Qualitative analysis of comments identified additional contextual considerations as themes. RESULTS: There were 45 participants (academic setting: 84%) representing 8 provinces (Ontario: 64%). Rounds 2 and 3 were completed by 42 and 33 participants, respectively. Nine indications reached consensus and agreement: presumed myxedema coma, presumed thyroid storm, atrial fibrillation/flutter, euvolemic hyponatremia, proptosis, adrenal insufficiency, hypothermia, thyroid medication noncompliance, and goiter. There was also agreement that two contextual considerations identified in thematic analysis, including a recent abnormal outpatient TSH, and the presence of other findings of thyroid dysfunction, would significantly change some mid-range responses. CONCLUSIONS: Canadian experts agreed upon nine specific indications for ordering an inpatient TSH, with others requiring consideration of previous TSH measurement and clinical context.

Nursing perspectives on the confusion assessment method: a qualitative focus group study.

Background: the Confusion Assessment Method (CAM) is commonly used to detect delirium. Although accurate when administered by trained researchers, its sensitivity is low when performed by nurses in clinical practice. We aimed to understand the perspectives of nurses who used the CAM on orthopaedic wards. Design: qualitative focus group study. Setting: two academic hospitals in Hamilton, Ontario, Canada. Participants: forty-three nurses who worked on orthopaedic inpatient units and used the CAM daily participated in one of eight focus group sessions. Measurements: structured focus groups explored nurses' perception of delirium and the use of the CAM. Each transcript was coded and sampling continued until theme saturation. Results: the participants (84% female, mean age 40 years, mean years in practice 12.8) had mixed feelings about the CAM. Some nurses praised its simplicity, while others preferred a narrative description of the delirium episode. Only 35% recalled receiving training to administer the CAM. Across the groups, disorientation was inappropriately used to evaluate level of consciousness and inattention. Objective testing was reportedly rarely used for assessing inattention. Most nurses retrospectively completed the CAM at the end of their shift by extrapolating from earlier observations rather than formally administering the tool. Reported challenges included differentiating delirium from dementia, assessing non-verbal patients and those with language barriers, time constraints, discrepancy with physicians' assessments and pressure to diagnose delirium. Conclusion: despite its widespread use, the CAM was poorly understood by orthopaedic nurses at two academic institutions. The CAM may be difficult to implement in practice.