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AdvertisementContinue reading the main storySupported byContinue reading the main storyDoctorsWhen the Cancer Doctor LeavesI knew how difficult it would be to tell my colleagues I was generic daily cialis online leaving for a new job. I didn’t anticipate how hard generic daily cialis online it would be to tell my patients.Credit...Aaron Josefczyk/ReutersJan. 14, 2021“I’ve known you since 2003,” my patient reminded me, after I had entered the examination room and took my usual seat a few feet away from her. She was sitting next to her husband, just as she had been at her first visit 17 years earlier, and both wore winter jackets to withstand the sleet that Cleveland had decided to generic daily cialis online dump on us in late October.

€œThat was when I first generic daily cialis online learned I had leukemia,” she added. He nodded dutifully, remembering the day.I was freshly out of my fellowship training in hematology-oncology back then, and still nervous every time I wrote a prescription for chemotherapy on my own, without an attending’s co-signature. In her case, it was for generic daily cialis online the drug imatinib, which had been on the market only a couple of years.At the time, a study had just reported that 95 percent of patients who had her type of leukemia and who were treated with the drug imatinib achieved a remission. But on average, patients in that study had generic daily cialis online been followed for just a year and a half, so I couldn’t predict for her how long the drug might work in her case.Seventeen years later, she was still in a remission.

During that time, she had retired from her job as a nurse, undergone a couple of knee replacements, and had a cardiac procedure to treat her atrial fibrillation.“You had a toddler at home,” she reminded me. That son generic daily cialis online was now in college. €œAnd then your generic daily cialis online daughter was born the next year. And you had another boy, right?.

€I nodded, and in turn reminded her of the grandchildren she had welcomed into the world during the generic daily cialis online same time. We had grown older together. Then we sat quietly, staring at each other and enjoying the shared memories.“I can’t believe you’re leaving me,” she said softly.When I decided to take a new job in Miami, I knew how difficult it would be generic daily cialis online to tell the other doctors, nurses, pharmacists and social workers I work with, the team from whom I had learned so much and relied upon so heavily for years.I didn’t anticipate how hard it would be to tell my patients.For some with longstanding, chronic cancers, it was like saying goodbye to a beloved friend or a comrade-in-arms, as if we were reflecting on having faced down an unforgiving foe together, and had lived to tell about it.For others, still receiving therapy for a leukemia that had not yet receded, I felt as if I were betraying them in medias res. I spent a lot of time reviewing generic daily cialis online their treatment plans and reinforcing how I would transition their care to another doctor, probably more to reassure myself than my patients, that they would be OK.A few were angry.

Unbeknownst to me, my hospital, ever efficient, had sent out a letter informing patients of my departure and offering the option to choose any one of eight other doctors who could assume their care — even before I had a chance to tell some of them in person. How were they expected to choose, and why hadn’t I told them I was leaving, they demanded indignantly.I felt the same way as my patients, and quickly sent out my own follow-up letter offering to select a specialist for their specific types of cancer, and telling my patients I would miss them.I then spent weeks apologizing, in person, for the generic daily cialis online first letter.And though I always tell my patients the best gift I could ever hope for is their good health, many brought presents or cards.One man in his 60s had just received another round of chemotherapy for a leukemia that kept coming back. I think we both knew that generic daily cialis online the next time the leukemia returned, it would be here to stay. When I entered his examination room, he greeted me where my other patient had left off.“I can’t believe you’re leaving me.”Before I could even take a seat, he handed me a plain brown bag with some white tissue paper poking out of the top and urged me to remove its contents.Inside was a drawing of the steel truss arches of Cleveland’s I-90 Innerbelt bridge, with the city skyline rising above it.“It’s beautiful,” I told him.

€œI don’t know what to say.”“You generic daily cialis online can hang this on your office wall in Miami,” he suggested, starting to cry. €œSo you’ll always remember Cleveland.” And then, erectile dysfunction treatment precautions be damned, he generic daily cialis online walked over and gave me a huge bear hug. After a few seconds we separated.“No,” I said, tearing up. €œI’ll hang up the picture and always remember you.”Mikkael Sekeres (@mikkaelsekeres), formerly the director of the leukemia program at the Cleveland Clinic, is the chief generic daily cialis online of the Division of Hematology, Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine and author of “When Blood Breaks Down.

Life Lessons From Leukemia.”AdvertisementContinue reading the main story.

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When it comes to diversity, equity and inclusion, most organizations cialis coupon 2020 and their leaders http://getananswer.co.uk/cheap-cipro-pills/ have a strong desire to drive systemic change not only within their organizations, but in the broader communities they serve. With so many leaders and organizations stepping up to provide safe spaces for these cialis coupon 2020 kinds of crucial conversations, we’re experiencing a revitalization of momentum toward true, much-needed change. Courageous, curious leaders are pushing for candid conversations and are becoming more comfortable with being uncomfortable.

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Do the work to embed diverse experiences and equity into every interaction, every cialis coupon 2020 step and every moment. Push the past the boundaries of your comfort—integrated as a daily practice.Challenge yourself and others to create safe spaces .Provide toolkits for difficult conversations.Share what’s cialis coupon 2020 working and be honest about what’s not.Be transparent about where you are as an organization. Listen and learn from your team members about their experiences.Integrate diversity, equity and inclusion into tangible, measurable outcomes that impact all that you do.What emerges from this vulnerability will astound you.

Leaders from every cialis coupon 2020 level of your organization will stand up, speak up and take action. Embrace and encourage these leaders and more will emerge. Move beyond the status quo, beyond checking boxes, and enact sustainable, positive change.The labor union representing 24,000 Kaiser Permanente employees is pausing participation in its labor-management partnership with the integrated health system and is prepared to ask its members to vote on a strike, union leaders said Friday.The United Nurses Associations of California/Union of Health Care Professionals, which includes registered nurses, pharmacists, rehab therapists, midwives and optometrists, also said the landmark labor-management partnership cialis coupon 2020 created in 1997 is "on life support."The union's collective bargaining agreements with the Oakland-based not-for-profit system expire within weeks.

The employer has offered a 1% across-the-board raise for union workers and a two-tiered pay scale that would reduce compensation for new hires compared to current employees starting in 2023, which the union does not support.Kaiser Permanente could not be reached for comment before this article published.Union workers say proposals like these, which reduce wages long term even though the company reported $2.2 billion in operating income in 2020, give them no choice but to pause the partnership and potentially call for a strike, the union said in a news release. Labor leaders worry cialis coupon 2020 Kaiser Permanente's proposals will worsen staff shortages as other healthcare providers offer raises, signing bonuses and other incentives to attract workers, especially nurses."We risked our lives and our own families' health to save people," Peter Sidhu, a registered nurse who has cared for erectile dysfunction treatment patients. Sidhu is the union's treasurer and a member of the bargaining committee negotiating with Kaiser Permanente."Some of us died from it.

Others still suffer cialis coupon 2020 long haul symptoms. We were without beds. We had cialis coupon 2020 patients in tents.

Not enough cialis coupon 2020 nurses. The employer should be thanking us. Instead, Kaiser Permanente has chosen to drive down wages and benefits," Sidhu said.The cialis coupon 2020 most recent bargaining session was Sept.

10 and no future meetings are currently scheduled, said Joe Guzynski, the union's executive director and chief negotiator."We're focusing on in-depth conversations with our members about these issues and what to do next. With most of our contracts set cialis coupon 2020 to expire on Sept. 30, if Kaiser Permanente intends to force these wage cuts, it could lead to nationwide actions, including a strike," Guzynski said.The Oregon Federation of Nurses and Health Professionals, which also belongs to the Alliance of Health Care Unions, is planning a rally in Portland Sept.

28 to protest staffing levels and proposed contract changes at Kaiser Permanente facilities.The labor management partnership is a 24-year-old agreement between the health system and its unions—now called the Coalition of Kaiser Permanente Unions and the Alliance cialis coupon 2020 of Health Care Unions—to jointly make decisions about patient care, access and quality.Workers don't want to strike and fear walking out would be unfair to the travel nurses at Kaiser Permanente sites, who would be heavily understaffed, said, Elizabeth Hawkins, a registered nurse and the union's secretary."This employer has an agenda that's being orchestrated from the top down, from Kaiser leadership and the board of directors, who I believe no longer believe in the partnership and working with the union," said Hawkins, who retired from Kaiser Permanente last March after 31 years. "We should be able to sit down and put the partnership principles to work and get to where we need to be."The health system likely narrowly avoided a strike by the Coalition of Kaiser Permanente Unions in September 2019 over contract negotiations, after agreeing to higher wages and a workforce development program.Private insurers are set to win big if House Democrats' plan to close the Medicaid expansion coverage gap passes Congress. The proposal, which passed a key committee this week, would create a new federal Medicaid look-alike program in non-expansion states, with its administration to be outsourced to managed care organizations and other third parties by the Health and Human Services Department through cialis coupon 2020 a bidding process.Managed-care organizations, which deliver Medicaid benefits on the behalf of states, already cover 54 million people, nearly 70% of Medicaid beneficiaries, according to the Kaiser Family Foundation.

The proposal would give MCOs the opportunity to cover more than 2 million uninsured low-income adults who live in the 12 states that have refused to expand Medicaid under the Affordable Care Act, mostly for political reasons. Most people in the coverage cialis coupon 2020 gap live in the South and are people of color. Another 2 million people who are currently eligible for ACA subsidies would also be eligible for Medicaid if the program was expanded, offering them more comprehensive benefits and lower cost-sharing than they receive under exchange coverage, according to KFF cialis coupon 2020.

"It's a big business opportunity to try to get these new enrollees because it's potentially a lot of people," said Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, where she studies health insurance markets. The majority of the people in the coverage gap live in Texas, North Carolina, Florida and Georgia, making those states the most enticing to cialis coupon 2020 insurers, she said. "If you think of those big four states, that's a really big deal," she said.

The drafters cialis coupon 2020 of the ACA intended Medicaid to cover all low-income adults in all 50 states, but the Supreme Court ruled in 2014 that was unconstitutional. Medicaid expansion became optional, with 38 states adopting it as of this year.Democrats gained control of both houses of Congress and the executive branch after the 2020 elections. They vowed to finally close cialis coupon 2020 the coverage gap.

Under the proposal, people in the coverage gap would become eligible for ACA subsidies to buy exchange plans until 2025, when the new federal program would start. Insurers have made a hard play for a solution cialis coupon 2020 that utilizes managed care. "We're urging Congress to make sure that we build on the existing Medicaid infrastructure," said Craig Kennedy, president and CEO of Medicaid Health Plans of America, which represents MCOs.

He noted that 40 states already have managed care organizations, including Texas, Georgia, North Carolina and Florida cialis coupon 2020. "We believe it would be more effective to leverage the existing managed care infrastructure to expand Medicaid to those uninsured populations." Many of cialis coupon 2020 the 38 states that have already expanded Medicaid contract with MCOs to manage those populations. But it's not entirely clear what would happen in the three non-expansion states that don't have any MCOs, though the legislation gives HHS the option to contract with a "third party plan administrator." North Carolina, another state that hasn't expanded Medicaid, recently contracted with several MCOs, including Centene Corp.

And UnitedHealth cialis coupon 2020 Group, to manage their program. Large national carriers Centene, UnitedHealthcare, Anthem, Molina Healthcare and Aetna have contracts to cover 60% of the Medicaid managed-care market, according to an analysis from KFF. Hempstead said there have been many entries into the ACA markets in non-expansion states, with insurers that operate MCOs potentially anticipating those states will eventually expand Medicaid or Congress will cialis coupon 2020 act to close the coverage gap.

Insurers may feel it gives them an advantage to already be serving customers in the marketplace or in Medicaid when it comes time to submit bids, she said. That's what cialis coupon 2020 regional and local plans are worried about. Regulators must ensure that community plans only operating in a certain area of the state are not disadvantaged through their bidding process, said Dan Jones, vice president of federal affairs at the Alliance of Community Health Plans.

Local and regional MCOs cialis coupon 2020 control about 40% of the market, according to KFF. "If you just had two bids across the whole non-expansion state, we have plans that operate within certain parts of the state," Jones said. "So, it seems like they would be disadvantaged if that's the route that they would go." The legislation says the HHS secretary can contract cialis coupon 2020 with more than one MCO or plan administrator in each coverage gap geographic area.

While the idea of offering a federal Medicaid option has been debated since at least the creation of the Affordable Care Act, the proposal to privatize the service cialis coupon 2020 is new, Jones said. Managed-care organizations in the past have been criticized for charging more for the administration of the plans than traditional, fee-for-service Medicaid. The ACA allows plans to keep 15% of the premiums collected on administration—the rest must be spent on cialis coupon 2020 members' medical care, which insurers measure through their medical loss ratios.

Some states have said local regulators operate the program more efficiently than private companies. In the run-up to privatizing healthcare for the state's most vulnerable population, the Oklahoma Health Care Authority, which supported moving to managed-care, said its administrative cialis coupon 2020 costs of running fee-for-service Medicare ran at just 5%, for example. The move to privatize Oklahoma's Medicaid program, named SoonerSelect, ultimately failed.

"In terms of what they're counting towards administrative cialis coupon 2020 costs, what benefits are included?. What type of coordination of care is provided to improve health outcomes and save costs?. " Jones cialis coupon 2020 said.

"I just think that there's a lot of variables that go into looking at the value that private companies provide." Medicaid managed-care organizations have also caught the attention of regulators recently. The federal government unsealed a whistleblower suit accusing cialis coupon 2020 Aetna of lying about its provider network to secure Medicaid contracts in Pennsylvania this week, although the Hartford, Connecticut-based insurer denies the claims. Aetna is cialis coupon 2020 owned by CVS Health.

The legislation gives the HHS secretary the power to set provider rates, network adequacy standards, quality requirements and any other standards he or she deems necessary. The contracts must also include a minimum MLR and a requirement for "timely" payments to providers."I cialis coupon 2020 don't think it's universally true that managed-care entities get it right," said Dr. Vikram Bakhru, chief medical officer at Medicaid managed-care startup Circulo.

"Certainly, you know, there are cases of failure." But he believed introducing private companies in the marketplace added a level of competition that would benefit the government and enrollees, cialis coupon 2020 and that managed-care companies' experience managing costs and care would ultimately translate to lower costs across the program, compared with a traditional fee-for-service option. As an example, he pointed to the success of the lucrative and growing Medicare Advantage market, a private alternative to fee-for-service Medicare that covers 26.7 million seniors, or more than 42% of all eligible seniors, according to the most recent federal data from July.In 2021, member satisfaction with their Medicare Advantage program increased for the third year in a row, according to a report from data analytics firm J.D. Powers.

But as satisfaction grew, so did federal spending. The cost per beneficiary is growing faster for people on Medicare Advantage than it is for people on traditional Medicare and Part D prescription drug plans, according to MedPAC. Medicare Advantage also makes up a larger portion of the federal budget, or 46%, than the enrollee population it serves, according to KFF.

"Is the private option a guaranteed solution?. No, of course not," Bakhru said. "But it represents an option that brings competition to the landscape, and I think that is a healthy component to the ecosystem." While privatizing a federal Medicaid plan would offer a short-term bump to those companies chosen to manage the program, the long-term proposal could negatively impact insurers since it could lead to a small portion of commercial members switching to Medicaid, which offers lower profit margins, said Glenn Melnick, a health finance professor at the University of Southern California.

In 2020, Medicaid managed-care enrollees delivered insurers the lowest profit margin across all plan types, according to KFF. "If you want to bid, and you only have one buyer, which is the federal government, they have the power in negotiating a contract," Melnick said. "I'm guessing all other things equal, commercial companies would rather keep their members commercial."Percy Allen II always tried to honor those who propelled his career in healthcare by encouraging young administrators.Allen, a longtime healthcare executive known for building morale at financially troubled healthcare organizations, spent much of his time in recent years taking calls from emerging leaders seeking his advice, his wife Fay Allen said."He advocated for people of color to be part of this diverse world and for them to be a part of this corporate system," Fay Allen said.

"They all learned from Percy's example and emulated some of his ideas and thoughts about equality at the corporate level for people of color."Percy Allen passed away Sunday at 80 years old. He is survived by his wife. His children, Merrily and Percy III.

His grandchildren, Narissa, Tiffany Littlejohn, Janice, Percy IV and Nelson. And his siblings, Invee Burrell and Yolanda Allen."I always encouraged young administrators. I've trained and mentored so many people.

I've touched them, and they've touched me," Percy Allen II said in 2011, the year he was inducted into the Modern Healthcare Hall of Fame."I've tried to be a role model, to lead by example. My success has been because I've had the opportunity to stand on the shoulders of others who went before me. They opened the doors and made the path clear,," Allen said at the time.Allen passed along the importance of cultivating the next generation of healthcare executives and increasing diversity among leaders of the field, Fay Allen said.

He mentored former CommonSpirit Health CEO Kevin Lofton and late Kaiser Permanente CEO Bernard Tyson, she said.David Ridderheim, former CEO of Parkview Memorial Hospital in Fort Wayne, Indiana, helped Allen get his start. At a time when most Black administrators were going into public hospitals, Ridderheim took a chance in hiring Allen to help run a hospital that probably had fewer than 10% Black patients. Allen also served as board chair of the Fort Wayne Urban League and participated in other civic activities.Allen's held leadership roles at several health systems around the country during his career.

He was assistant administrator at Parkview, interim CEO at Sinai Hospital in Detroit, chief executive officer of North Central Bronx hospital in New York, CEO of University of Brooklyn SUNY Health Science Center in New York and chief executive of Bon Secours Health System in Baltimore.Allen's coworkers described him as a friendly, warm and unassuming man who quickly forged strong bonds and relationships, they said in a Modern Healthcare profile published in 2011.Allen was known for turning around failing hospitals by investing in long-delayed capital improvements. He helped instill a culture of customer and employee satisfaction by sprucing up workplaces with new artwork and thoughtful landscape architecture. He also established a high school health center in Brooklyn, New York, and refurbished community housing units in Baltimore, among other community projects.An influential federal advisory panel has overwhelmingly rejected a plan to give Pfizer booster shots against erectile dysfunction treatment to most Americans, but it endorsed the extra shots for those who are 65 or older or run a high risk of severe disease.The twin votes Friday represented a heavy blow to the Biden administration's sweeping effort to shore up nearly all Americans' protection amid the spread of the highly contagious delta variant.The decision was made by a committee of outside experts who advise the Food and Drug Administration.The first vote by the committee of outside experts assembled by the Food and Drug Administration was 16-2, with members expressing frustration that Pfizer had provided little data on the safety of extra doses.

Many also raised doubts about the value of mass boosters, rather than ones targeted to specific groups.In an extraordinary move, both FDA leaders and the panel indicated they were likely to take a second vote Friday afternoon on recommending the booster shots for older Americans and other high-risk groups.That would help salvage part of the White House's campaign but would still be a huge step back from the sweeping plan proposed by administration a month ago to offer booster shots of both the Pfizer and Moderna treatments to nearly all Americans eight months after they get their second dose.During several hours of vigorous debate Friday, members of the panel questioned the value of offering boosters to nearly everyone.“I don’t think a booster dose is going to significantly contribute to controlling the cialis,” said Dr. Cody Meissner of Tufts University. €œAnd I think it’s important that the main message we transmit is that we’ve got to get everyone two doses.”Dr.

Amanda Cohn of the Centers for Disease Control and Prevention said. "At this moment it is clear that the unvaccinated are driving transmission in the United States.”Panel members also complained that data provided by Israeli researchers about their booster campaign might not be suitable for predicting the U.S. Experience.Scientists inside and outside the government have been divided in recent days over the need for boosters and who should get them, and the World Health Organization has strongly objected to rich nations giving a third round of shots when poor countries don’t have enough treatment for their first.While research suggests immunity levels in those who have been vaccinated wane over time and boosters can reverse that, the Pfizer treatment is still highly protective against severe illness and death, even amid the spread of the highly contagious delta variant.The surprise turn of events could reinforce recent criticism that the Biden administration got out ahead of the science in its push for boosters.

President Joe Biden promised early on that his administration would “follow the science,” following disclosures of political meddling in the Trump administration’s erectile dysfunction response.The FDA advisory panel was the first major hurdle that the Biden administration plan faced. The FDA itself has yet to make its own determination but typically follows the recommendations of its expert panel.In yet another step to the process, a CDC advisory committee that sets policy for U.S. Vaccinations campaigns is set to meet on Wednesday to debate who, exactly, should get boosters and how many months after their second dose should them receive the extra shot.The CDC has said it is considering boosters for older people, nursing home residents and front-line health care workers, rather than all adults.Separate FDA and CDC decisions will be needed in order for people who received the Moderna or J&J shots to get boosters.The FDA panel's overwhelming rejection came despite full-throated arguments about the need for boosters from both Pfizer and health officials from Israel, which began offering boosters to its citizens in July.Sharon Alroy-Preis of Israel’s Ministry of Health said the booster dose improves protection tenfold against in people 60 and older.“It’s like a fresh treatment,” bringing protection back to original levels and helping Israel “dampen severe cases in the fourth wave,” she said.And representatives for Pfizer argued that it is important to shore up immunity before protection against severe disease starts to erode.

A company study of 44,000 people showed effectiveness against symptomatic erectile dysfunction treatment was 96% two months after the second dose, but had dropped to 84% by around six months.Both Pfizer and the Israeli representatives faced pushback from panelists. Several expressed skepticism about the relevance of Israel’s experience to the U.S. Another concern was whether third doses would exacerbate serious side effects.Meissner said he is worried about extra doses for younger age groups given the risk of heart inflammation that has been seen in mostly younger men after a second dose.

While the condition is very rare, he said, it is not clear if that risk would increase with another dose.Pfizer pointed to Israeli data from nearly 3 million boosters to suggest side effect rates would be similar to that seen after second doses.Dr. Paul Offit, a treatment expert at Children’s Hospital of Philadelphia, said he was more likely to support approving a third dose for adults over 60 or 65 but “I really have trouble” supporting it for anyone down to age 16.While an extra shot likely will at least temporarily decrease cases with mild or no symptoms, “the question becomes what will be the impact of that on the arc of the cialis, which may not be all that much,” Offit said.Biden’s top health advisers, including the heads of the FDA and CDC, first announced plans for widespread booster shots a month ago, targeting the week of Sept. 20 as an all-but-certain start date.

But that was before FDA staff scientists had completed their own assessments of the data.Earlier this week, two top FDA treatment reviewers joined a group of international scientists in publishing an editorial rejecting the need for boosters in healthy people. The scientists said continuing studies show the shots are working well despite the delta variant.On Friday, U.S. Surgeon General Dr.

Vivek Murthy said that in announcing its booster plan, the Biden administration was not trying to pressure regulators to act but was instead trying to be transparent with the public and be prepared in the event that extra shots won approval.“We have always said that this initial plan would be contingent on the FDA and the CDC’s independent evaluation,” Murthy said.The Biden plan has also raised major ethical concerns about impoverished parts of the world still clamoring for treatment. But the administration has argued that the plan is not an us-or-them choice, noting that the U.S. Is supplying large quantities of treatment to the rest of the globe.The U.S.

Has already approved Pfizer and Moderna boosters for certain people with weakened immune systems, such as cancer patients and transplant recipients.Some Americans, healthy or not, have managed to get boosters, in some cases simply by showing up and asking for a shot. And some health systems already are offering extra doses to high-risk people..

When it comes to diversity, equity and inclusion, most organizations and their leaders have a strong desire to drive systemic change not generic daily cialis online only within their organizations, but in the Source broader communities they serve. With so many leaders and organizations stepping up to provide safe spaces for these kinds of generic daily cialis online crucial conversations, we’re experiencing a revitalization of momentum toward true, much-needed change. Courageous, curious leaders are pushing for candid conversations and are becoming more comfortable with being uncomfortable.

But we must not lose sight of the long, tough journey generic daily cialis online ahead. While you may not be as far down the path as you’d hoped, or maybe you are unsure just how to start on your DEI journey, taking time to reflect is the only way to move forward from being reactive to becoming proactive. Being vulnerable about where you are as an organization and taking stock of the hard truths will make your next generic daily cialis online steps clear.

As you navigate the path, remember that change happens in moments. Each small generic daily cialis online step, conversation and action builds on the next to create a strong foundation for diversity, equity and inclusion. Find an entry point and work as a team, as an organization and as a community to find the spaces in between and fill them with determination, focus and discipline to close the gap.

Do the work to embed diverse experiences and equity into every interaction, generic daily cialis online every step and every moment. Push the past the boundaries of your comfort—integrated as a daily practice.Challenge yourself and others to create safe spaces .Provide toolkits for difficult conversations.Share what’s working and be generic daily cialis online honest about what’s not.Be transparent about where you are as an organization. Listen and learn from your team members about their experiences.Integrate diversity, equity and inclusion into tangible, measurable outcomes that impact all that you do.What emerges from this vulnerability will astound you.

Leaders from every level of your organization will stand up, speak up and generic daily cialis online take action. Embrace and encourage these leaders and more will emerge. Move beyond the status quo, beyond checking boxes, and enact sustainable, positive change.The labor union representing 24,000 Kaiser Permanente employees is pausing participation in its labor-management partnership with the integrated health system and is prepared to ask its members to vote on a strike, union leaders said Friday.The United Nurses Associations of California/Union of Health Care Professionals, which includes registered nurses, pharmacists, rehab therapists, midwives and optometrists, also said the landmark labor-management partnership created in 1997 is generic daily cialis online "on life support."The union's collective bargaining agreements with the Oakland-based not-for-profit system expire within weeks.

The employer has offered a 1% across-the-board raise for union workers and a two-tiered pay scale that would reduce compensation for new hires compared to current employees starting in 2023, which the union does not support.Kaiser Permanente could not be reached for comment before this article published.Union workers say proposals like these, which reduce wages long term even though the company reported $2.2 billion in operating income in 2020, give them no choice but to pause the partnership and potentially call for a strike, the union said in a news release. Labor leaders worry Kaiser Permanente's proposals will worsen staff shortages generic daily cialis online as other healthcare providers offer raises, signing bonuses and other incentives to attract workers, especially nurses."We risked our lives and our own families' health to save people," Peter Sidhu, a registered nurse who has cared for erectile dysfunction treatment patients. Sidhu is the union's treasurer and a member of the bargaining committee negotiating with Kaiser Permanente."Some of us died from it.

Others still generic daily cialis online suffer long haul symptoms. We were without beds. We had generic daily cialis online patients in tents.

Not enough generic daily cialis online nurses. The employer should be thanking us. Instead, Kaiser Permanente has chosen to drive down wages and benefits," Sidhu said.The most recent bargaining session generic daily cialis online was Sept.

10 and no future meetings are currently scheduled, said Joe Guzynski, the union's executive director and chief negotiator."We're focusing on in-depth conversations with our members about these issues and what to do next. With most of our contracts set to expire generic daily cialis online on Sept. 30, if Kaiser Permanente intends to force these wage cuts, it could lead to nationwide actions, including a strike," Guzynski said.The Oregon Federation of Nurses and Health Professionals, which also belongs to the Alliance of Health Care Unions, is planning a rally in Portland Sept.

28 to protest staffing levels and proposed contract changes at Kaiser Permanente facilities.The labor management partnership is a 24-year-old agreement between the health system and its unions—now called the Coalition of Kaiser Permanente Unions and the Alliance of Health Care Unions—to jointly make decisions about patient care, access and quality.Workers don't want to strike and generic daily cialis online fear walking out would be unfair to the travel nurses at Kaiser Permanente sites, who would be heavily understaffed, said, Elizabeth Hawkins, a registered nurse and the union's secretary."This employer has an agenda that's being orchestrated from the top down, from Kaiser leadership and the board of directors, who I believe no longer believe in the partnership and working with the union," said Hawkins, who retired from Kaiser Permanente last March after 31 years. "We should be able to sit down and put the partnership principles to work and get to where we need to be."The health system likely narrowly avoided a strike by the Coalition of Kaiser Permanente Unions in September 2019 over contract negotiations, after agreeing to higher wages and a workforce development program.Private insurers are set to win big if House Democrats' plan to close the Medicaid expansion coverage gap passes Congress. The proposal, which generic daily cialis online passed a key committee this week, would create a new federal Medicaid look-alike program in non-expansion states, with its administration to be outsourced to managed care organizations and other third parties by the Health and Human Services Department through a bidding process.Managed-care organizations, which deliver Medicaid benefits on the behalf of states, already cover 54 million people, nearly 70% of Medicaid beneficiaries, according to the Kaiser Family Foundation.

The proposal would give MCOs the opportunity to cover more than 2 million uninsured low-income adults who live in the 12 states that have refused to expand Medicaid under the Affordable Care Act, mostly for political reasons. Most people in the coverage generic daily cialis online gap live in the South and are people of color. Another 2 million people who are currently eligible for ACA subsidies would also be eligible for Medicaid if the program was expanded, offering them more comprehensive benefits and lower cost-sharing than they receive under exchange coverage, according to KFF generic daily cialis online.

"It's a big business opportunity to try to get these new enrollees because it's potentially a lot of people," said Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, where she studies health insurance markets. The majority of the people in the coverage gap live in Texas, North Carolina, Florida and Georgia, making those states the most enticing generic daily cialis online to insurers, she said. "If you think of those big four states, that's a really big deal," she said.

The drafters of the ACA intended Medicaid to cover all low-income adults in all 50 states, but the Supreme Court generic daily cialis online ruled in 2014 that was unconstitutional. Medicaid expansion became optional, with 38 states adopting it as of this year.Democrats gained control of both houses of Congress and the executive branch after the 2020 elections. They vowed to generic daily cialis online finally close the coverage gap.

Under the proposal, people in the coverage gap would become eligible for ACA subsidies to buy exchange plans until 2025, when the new federal program would start. Insurers have generic daily cialis online made a hard play for a solution that utilizes managed care. "We're urging Congress to make sure that we build on the existing Medicaid infrastructure," said Craig Kennedy, president and CEO of Medicaid Health Plans of America, which represents MCOs.

He noted that 40 states already generic daily cialis online have managed care organizations, including Texas, Georgia, North Carolina and Florida. "We believe it would be more effective to leverage the existing managed care infrastructure to generic daily cialis online expand Medicaid to those uninsured populations." Many of the 38 states that have already expanded Medicaid contract with MCOs to manage those populations. But it's not entirely clear what would happen in the three non-expansion states that don't have any MCOs, though the legislation gives HHS the option to contract with a "third party plan administrator." North Carolina, another state that hasn't expanded Medicaid, recently contracted with several MCOs, including Centene Corp.

And UnitedHealth Group, to manage their generic daily cialis online program. Large national carriers Centene, UnitedHealthcare, Anthem, Molina Healthcare and Aetna have contracts to cover 60% of the Medicaid managed-care market, according to an analysis from KFF. Hempstead said there have been many entries into the ACA markets in non-expansion states, with insurers that operate generic daily cialis online MCOs potentially anticipating those states will eventually expand Medicaid or Congress will act to close the coverage gap.

Insurers may feel it gives them an advantage to already be serving customers in the marketplace or in Medicaid when it comes time to submit bids, she said. That's what regional and local plans are generic daily cialis online worried about. Regulators must ensure that community plans only operating in a certain area of the state are not disadvantaged through their bidding process, said Dan Jones, vice president of federal affairs at the Alliance of Community Health Plans.

Local and regional MCOs control generic daily cialis online about 40% of the market, according to KFF. "If you just had two bids across the whole non-expansion state, we have plans that operate within certain parts of the state," Jones said. "So, it seems like they would be disadvantaged if that's the route that they would go." The legislation says the HHS secretary can contract with more than one generic daily cialis online MCO or plan administrator in each coverage gap geographic area.

While the idea of offering a federal Medicaid option has been debated since at least the creation of the Affordable Care Act, the proposal to privatize the service is new, Jones generic daily cialis online said. Managed-care organizations in the past have been criticized for charging more for the administration of the plans than traditional, fee-for-service Medicaid. The ACA allows plans to keep 15% of the premiums collected generic daily cialis online on administration—the rest must be spent on members' medical care, which insurers measure through their medical loss ratios.

Some states have said local regulators operate the program more efficiently than private companies. In the run-up to privatizing healthcare for the state's most vulnerable population, the Oklahoma Health Care Authority, which supported moving to managed-care, generic daily cialis online said its administrative costs of running fee-for-service Medicare ran at just 5%, for example. The move to privatize Oklahoma's Medicaid program, named SoonerSelect, ultimately failed.

"In terms of what they're generic daily cialis online counting towards administrative costs, what benefits are included?. What type of coordination of care is provided to improve health outcomes and save costs?. " Jones generic daily cialis online said.

"I just think that there's a lot of variables that go into looking at the value that private companies provide." Medicaid managed-care organizations have also caught the attention of regulators recently. The federal generic daily cialis online government unsealed a whistleblower suit accusing Aetna of lying about its provider network to secure Medicaid contracts in Pennsylvania this week, although the Hartford, Connecticut-based insurer denies the claims. Aetna is owned by CVS generic daily cialis online Health.

The legislation gives the HHS secretary the power to set provider rates, network adequacy standards, quality requirements and any other standards he or she deems necessary. The contracts must also include a minimum MLR and a requirement for "timely" payments to providers."I don't think it's universally true that managed-care entities get it right," generic daily cialis online said Dr. Vikram Bakhru, chief medical officer at Medicaid managed-care startup Circulo.

"Certainly, you know, there are cases of failure." But he believed introducing private companies in the marketplace added a level of competition that would generic daily cialis online benefit the government and enrollees, and that managed-care companies' experience managing costs and care would ultimately translate to lower costs across the program, compared with a traditional fee-for-service option. As an example, he pointed to the success of the lucrative and growing Medicare Advantage market, a private alternative to fee-for-service Medicare that covers 26.7 million seniors, or more than 42% of all eligible seniors, according to the most recent federal data from July.In 2021, member satisfaction with their Medicare Advantage program increased for the third year in a row, according to a report from data analytics firm J.D. Powers.

But as satisfaction grew, so did federal spending. The cost per beneficiary is growing faster for people on Medicare Advantage than it is for people on traditional Medicare and Part D prescription drug plans, according to MedPAC. Medicare Advantage also makes up a larger portion of the federal budget, or 46%, than the enrollee population it serves, according to KFF.

"Is the private option a guaranteed solution?. No, of course not," Bakhru said. "But it represents an option that brings competition to the landscape, and I think that is a healthy component to the ecosystem." While privatizing a federal Medicaid plan would offer a short-term bump to those companies chosen to manage the program, the long-term proposal could negatively impact insurers since it could lead to a small portion of commercial members switching to Medicaid, which offers lower profit margins, said Glenn Melnick, a health finance professor at the University of Southern California.

In 2020, Medicaid managed-care enrollees delivered insurers the lowest profit margin across all plan types, according to KFF. "If you want to bid, and you only have one buyer, which is the federal government, they have the power in negotiating a contract," Melnick said. "I'm guessing all other things equal, commercial companies would rather keep their members commercial."Percy Allen II always tried to honor those who propelled his career in healthcare by encouraging young administrators.Allen, a longtime healthcare executive known for building morale at financially troubled healthcare organizations, spent much of his time in recent years taking calls from emerging leaders seeking his advice, his wife Fay Allen said."He advocated for people of color to be part of this diverse world and for them to be a part of this corporate system," Fay Allen said.

"They all learned from Percy's example and emulated some of his ideas and thoughts about equality at the corporate level for people of color."Percy Allen passed away Sunday at 80 years old. He is survived by his wife. His children, Merrily and Percy III.

His grandchildren, Narissa, Tiffany Littlejohn, Janice, Percy IV and Nelson. And his siblings, Invee Burrell and Yolanda Allen."I always encouraged young administrators. I've trained and mentored so many people.

I've touched them, and they've touched me," Percy Allen II said in 2011, the year he was inducted into the Modern Healthcare Hall of Fame."I've tried to be a role model, to lead by example. My success has been because I've had the opportunity to stand on the shoulders of others who went before me. They opened the doors and made the path clear,," Allen said at the time.Allen passed along the importance of cultivating the next generation of healthcare executives and increasing diversity among leaders of the field, Fay Allen said.

He mentored former CommonSpirit Health CEO Kevin Lofton and late Kaiser Permanente CEO Bernard Tyson, she said.David Ridderheim, former CEO of Parkview Memorial Hospital in Fort Wayne, Indiana, helped Allen get his start. At a time when most Black administrators were going into public hospitals, Ridderheim took a chance in hiring Allen to help run a hospital that probably had fewer than 10% Black patients. Allen also served as board chair of the Fort Wayne Urban League and participated in other civic activities.Allen's held leadership roles at several health systems around the country during his career.

He was assistant administrator at Parkview, interim CEO at Sinai Hospital in Detroit, chief executive officer of North Central Bronx hospital in New York, CEO of University of Brooklyn SUNY Health Science Center in New York and chief executive of Bon Secours Health System in Baltimore.Allen's coworkers described him as a friendly, warm and unassuming man who quickly forged strong bonds and relationships, they said in a Modern Healthcare profile published in 2011.Allen was known for turning around failing hospitals by investing in long-delayed capital improvements. He helped instill a culture of customer and employee satisfaction by sprucing up workplaces with new artwork and thoughtful landscape architecture. He also established a high school health center in Brooklyn, New York, and refurbished community housing units in Baltimore, among other community projects.An influential federal advisory panel has overwhelmingly rejected a plan to give Pfizer booster shots against erectile dysfunction treatment to most Americans, but it endorsed the extra shots for those who are 65 or older or run a high risk of severe disease.The twin votes Friday represented a heavy blow to the Biden administration's sweeping effort to shore up nearly all Americans' protection amid the spread of the highly contagious delta variant.The decision was made by a committee of outside experts who advise the Food and Drug Administration.The first vote by the committee of outside experts assembled by the Food and Drug Administration was 16-2, with members expressing frustration that Pfizer had provided little data on the safety of extra doses.

Many also raised doubts about the value of mass boosters, rather than ones targeted to specific groups.In an extraordinary move, both FDA leaders and the panel indicated they were likely to take a second vote Friday afternoon on recommending the booster shots for older Americans and other high-risk groups.That would help salvage part of the White House's campaign but would still be a huge step back from the sweeping plan proposed by administration a month ago to offer booster shots of both the Pfizer and Moderna treatments to nearly all Americans eight months after they get their second dose.During several hours of vigorous debate Friday, members of the panel questioned the value of offering boosters to nearly everyone.“I don’t think a booster dose is going to significantly contribute to controlling the cialis,” said Dr. Cody Meissner of Tufts University. €œAnd I think it’s important that the main message we transmit is that we’ve got to get everyone two doses.”Dr.

Amanda Cohn of the Centers for Disease Control and Prevention said. "At this moment it is clear that the unvaccinated are driving transmission in the United States.”Panel members also complained that data provided by Israeli researchers about their booster campaign might not be suitable for predicting the U.S. Experience.Scientists inside and outside the government have been divided in recent days over the need for boosters and who should get them, and the World Health Organization has strongly objected to rich nations giving a third round of shots when poor countries don’t have enough treatment for their first.While research suggests immunity levels in those who have been vaccinated wane over time and boosters can reverse that, the Pfizer treatment is still highly protective against severe illness and death, even amid the spread of the highly contagious delta variant.The surprise turn of events could reinforce recent criticism that the Biden administration got out ahead of the science in its push for boosters.

President Joe Biden promised early on that his administration would “follow the science,” following disclosures of political meddling in the Trump administration’s erectile dysfunction response.The FDA advisory panel was the first major hurdle that the Biden administration plan faced. The FDA itself has yet to make its own determination but typically follows the recommendations of its expert panel.In yet another step to the process, a CDC advisory committee that sets policy for U.S. Vaccinations campaigns is set to meet on Wednesday to debate who, exactly, should get boosters and how many months after their second dose should them receive the extra shot.The CDC has said it is considering boosters for older people, nursing home residents and front-line health care workers, rather than all adults.Separate FDA and CDC decisions will be needed in order for people who received the Moderna or J&J shots to get boosters.The FDA panel's overwhelming rejection came despite full-throated arguments about the need for boosters from both Pfizer and health officials from Israel, which began offering boosters to its citizens in July.Sharon Alroy-Preis of Israel’s Ministry of Health said the booster dose improves protection tenfold against in people 60 and older.“It’s like a fresh treatment,” bringing protection back to original levels and helping Israel “dampen severe cases in the fourth wave,” she said.And representatives for Pfizer argued that it is important to shore up immunity before protection against severe disease starts to erode.

A company study of 44,000 people showed effectiveness against symptomatic erectile dysfunction treatment was 96% two months after the second dose, but had dropped to 84% by around six months.Both Pfizer and the Israeli representatives faced pushback from panelists. Several expressed skepticism about the relevance of Israel’s experience to the U.S. Another concern was whether third doses would exacerbate serious side effects.Meissner said he is worried about extra doses for younger age groups given the risk of heart inflammation that has been seen in mostly younger men after a second dose.

While the condition is very rare, he said, it is not clear if that risk would increase with another dose.Pfizer pointed to Israeli data from nearly 3 million boosters to suggest side effect rates would be similar to that seen after second doses.Dr. Paul Offit, a treatment expert at Children’s Hospital of Philadelphia, said he was more likely to support approving a third dose for adults over 60 or 65 but “I really have trouble” supporting it for anyone down to age 16.While an extra shot likely will at least temporarily decrease cases with mild or no symptoms, “the question becomes what will be the impact of that on the arc of the cialis, which may not be all that much,” Offit said.Biden’s top health advisers, including the heads of the FDA and CDC, first announced plans for widespread booster shots a month ago, targeting the week of Sept. 20 as an all-but-certain start date.

But that was before FDA staff scientists had completed their own assessments of the data.Earlier this week, two top FDA treatment reviewers joined a group of international scientists in publishing an editorial rejecting the need for boosters in healthy people. The scientists said continuing studies show the shots are working well despite the delta variant.On Friday, U.S. Surgeon General Dr.

Vivek Murthy said that in announcing its booster plan, the Biden administration was not trying to pressure regulators to act but was instead trying to be transparent with the public and be prepared in the event that extra shots won approval.“We have always said that this initial plan would be contingent on the FDA and the CDC’s independent evaluation,” Murthy said.The Biden plan has also raised major ethical concerns about impoverished parts of the world still clamoring for treatment. But the administration has argued that the plan is not an us-or-them choice, noting that the U.S. Is supplying large quantities of treatment to the rest of the globe.The U.S.

Has already approved Pfizer and Moderna boosters for certain people with weakened immune systems, such as cancer patients and transplant recipients.Some Americans, healthy or not, have managed to get boosters, in some cases simply by showing up and asking for a shot. And some health systems already are offering extra doses to high-risk people..

What if I miss a dose?

If you miss a dose, you may take it when you remember but do not take more than one dose per day.

Cialis for sale

Lauren Gambill, MDPediatrician, AustinMember, Texas Medical Association cialis for sale (TMA) Committee on Child and Adolescent HealthExecutive Board Member, Texas http://eclectic-oddities.com/?page_id=150 Pediatric SocietyDoctors are community leaders. This role has become even more important during the erectile dysfunction treatment cialis. As patients navigate our new reality, they are cialis for sale looking to us to determine what is safe, how to protect their families, and the future of their health care. As more Texans lose their jobs, their health insurance, or even their homes, it is crucial that Texas receives the resources it needs to uphold our social safety net.

The U.S. Census helps determine funding for those resources, and that is why it is of the upmost importance that each and every Texan, no matter address, immigration status, or age, respond to cialis for sale the 2020 U.S. Census. The deadline has been cut short one month and cialis for sale now closes Sept.

30.erectile dysfunction treatment has only increased the importance of completing the census to help our local communities and economies recover. The novel erectile dysfunction has inflicted unprecedented strain on patients and exacerbated inequality as more people are out of work and are many in need of help with food, health care, housing, and more. Schools also have been stretched thin, with teachers cialis for sale scrambling to teach students online. Yet, the amount of federal funding Texas has available today to help weather this emergency was driven in part by the census responses made a decade ago.

Getting an accurate count in 2020 will help Texans prepare for the decade to follow, the first few years of which most certainly will be spent rebuilding from the cialis’s fallout. Therefore, it cialis for sale is vital that all Texans be counted.The federal dollars Texas receives generally depends on our population. A George Washington University study recently found that even a 1% undercount can lead to a $300 million loss in funding.Take Medicaid, for example. Federal funds pay for 60% of the state’s program, which provides health coverage for two out of five Texas children, one in three individuals with disabilities, and 53% cialis for sale of all births.

The complicated formula used to calculate the federal portion of this funding depends on accurate census data. If Texas’ population is undercounted, Texans may appear better off financially than they really are, resulting in Texas getting fewer federal Medicaid dollars. If that happens, lawmakers will have to make up the difference, with cuts in services, program eligibility, or physician and provider payments, any of which are potentially detrimental.The census data also is key to funding other aspects of a community’s social safety net:Health careThe Children’s Health Insurance cialis for sale Program (CHIP) provides low-cost health insurance to children whose parents make too much to qualify for Medicaid, but not enough to afford quality coverage. Like Medicaid, how much money the federal government reimburses the state for the program depends in part on the census.Maternal and child health programs that promote public health and help ensure children are vaccinated relies on data from the census.

Texas also uses this federal cialis for sale funding to study and respond to maternal mortality and perinatal depression.Food and housing As unemployment rises and families struggle financially, many live with uncertainty as to where they will find their next meal. Already, one in seven Texans experiences food insecurity, and 20% of Texas children experience hunger. Food insecurity is rising in Texas as the cialis continues. The Central Texas Food Bank saw a 206% rise cialis for sale in clients in March.

Funding for the Supplemental Nutrition Assistance Program and school lunch programs are both determined by the census. Funding for local housing programs also is calculated via the census. An accurate count will help ensure that people who lose their homes during this economic crisis have better cialis for sale hope of finding shelter while our communities recover. Homelessness is closely connected with declines in overall physical and mental health.Childcare and educationAs we navigate the new reality brought on by erectile dysfunction, more parents are taking on roles as breadwinner, parent, teacher, and caretaker.

This stress highlights the desperate need for cialis for sale affordable childcare. The census determines funding for programs like Head Start that provide comprehensive early childhood education to low-income families. The good news is you still have time to complete the census. Visit 2020census.gov cialis for sale to take it.

It takes less than five minutes to complete. Then talk to your family, cialis for sale neighbors, and colleagues about doing the same. If you are wondering who counts, the answer is everyone, whether it’s a newborn baby, child in foster care, undocumented immigrant, or an individual experiencing homelessness.Completing the census is one of the best things that you can do for the health of your community, especially during the cialis. Thank you for helping Texas heal and for supporting these essential safety net programs.(L to R).

UTHSA medical students Swetha Maddipudi, Brittany Hansen, Charles Wang, Carson Cortino, faculty advisor Kaparaboyna cialis for sale Kumar, MD, Ryan Wealther, Sidney Akabogu, Irma Ruiz, and Frank Jung pose with the TMA Be Wise Immunize banner. Photo courtesy by Ryan WealtherRyan WealtherMedical Student, UT Health San Antonio Long School of MedicineStudent Member, Texas Medical AssociationEditor’s Note. August is National Immunization Awareness Month. This article is part of a Me&My Doctor series highlighting and promoting the use of vaccinations.“Can the flu shot cialis for sale give you the flu?.

€â€œIs it dangerous for pregnant women to get a flu shot?. €â€œCan treatments cause autism? cialis for sale. €These were questions women at Alpha Home, a residential substance abuse rehabilitation center in San Antonio, asked my fellow medical students and me during a flu treatment discussion. It is easy to see why these questions were asked, as treatment misinformation is common today.UTHSA medical student Frank Jing (left) gets a treatment fromKaparaboyna Kumar, MD, (right).Photo courtesy of Ryan Wealther“No” is the answer to all the questions.

These were exactly the types of myths we set out to dispel at our vaccination drive.UT Health San Antonio Long School of Medicine medical students (under the supervision of Kaparaboyna Ashok Kumar, MD, faculty advisor for the Texas Medical Association Medical Student Section at UT Health San Antonio) hosted the treatment drive at Alpha Home with the support of TMA’s Be Wise – Immunize℠ program, a public health initiative that aims to increase vaccinations and treatment awareness cialis for sale through shot clinics and education. Our program consisted of a vaccination drive and an interactive, educational presentation that addressed influenza, common flu shot questions, and general treatment myths. The Alpha Home residents could ask us questions during the program.We were interested to see if our educational program could cialis for sale answer Alpha Home residents’ questions about vaccinations and allay their hesitations about getting a flu vaccination. To gauge this, we created a brief survey.(Before I discuss the results of the survey, I should define treatment hesitancy.

treatment hesitancy is a concept defined by the World Health Organization. It relates to when cialis for sale patients do not vaccinate despite having access to treatments. treatment hesitancy is a problem because it prevents individuals from receiving their vaccinations. That makes them more susceptible to getting sick from treatment-preventable diseases.)We surveyed the residents’ opinions about vaccinations before and after our educational program.

While opinions about shots improved with each survey question, we saw the most significant attitude change reflected in answers to the questions “I am concerned that vaccinations might not be safe,” and “How likely are you to receive a flu cialis for sale shot today?. € We had informed the residents and improved their understanding and acceptance of immunizations.Post-survey results show more residents at the Alpha Home shifted to more positive attitudes about treatments, after learning more about their effectiveness by trusted members of the medical community. Graph by Ryan WealtherWhy is this important? cialis for sale. First, our findings confirm what we already knew.

Education by a trusted member of the medical community can effect change. In fact, it is widely known cialis for sale that physician recommendation of vaccination is one of the most critical factors affecting whether patients receive an influenza vaccination. Perhaps some added proof to this is that a few of the Alpha Home residents were calling me “Dr. Truth” by the end of cialis for sale the evening.Second, our findings add to our understanding of adult treatment hesitancy.

This is significant because most of what we know about treatment hesitancy is limited to parental attitudes toward their children’s vaccinations. Some parents question shots for their children, and many of the most deadly diseases we vaccinate against are given in childhood, including polio, tetanus, measles, and whooping cough shots. However, adults cialis for sale need some vaccinations as well, like the yearly influenza treatment. After taking part in the UTHSA educational program, more residents at the Alpha Home shared more willingness to receive the flu treatment.

Graph by Ryan WealtherAnother reason improving attitudes is important is that receiving a flu shot is even more timely during the erectile dysfunction treatment cialis because it decreases illnesses and conserves health care resources. Thousands of people each year are hospitalized from the flu, and with hospitals filling up cialis for sale with erectile dysfunction patients, we could avoid adding dangerously ill flu patients to the mix. Lastly, these findings are important because once a erectile dysfunction treatment vaccination becomes available, more people might be willing to receive it if their overall attitude toward immunizations is positive. Though the erectile dysfunction treatment is still in development, it cialis for sale is not immune to treatment hesitancy.

Recent polls have indicated up to one-third of Americans would not receive a erectile dysfunction treatment even if it were accessible and affordable. Work is already being done to try to raise awareness and acceptance. In addition, misinformation about the erectile dysfunction treatment cialis for sale treatment is circulating widely. (Someone recently asked me if the erectile dysfunction treatment will implant a microchip in people, and I have seen the same myth circulating on social media.

It will not.) This myth, however, illustrates the need for health care professionals to answer patients’ questions and to assuage their concerns.treatments work best when many people in a community receive them, and treatment hesitancy can diminish vaccination rates, cialis for sale leaving people who can't get certain treatments susceptible to these treatment-preventable diseases. For example, babies under 6 months of age should not receive a flu shot, so high community vaccination rates protect these babies from getting sick with the flu. Our educational program at Alpha Home is just one example of how health care professionals can increase awareness and acceptance of shots. As the erectile dysfunction treatment cialis progresses, we need to ensure children and adults receive cialis for sale their vaccinations as recommended by their physician and the Centers for Disease Control and Prevention.

I encourage readers who have questions about the vaccinations they or their child may need to talk with their physician. As health care professionals, we’re more than happy to answer your questions..

Lauren Gambill, MDPediatrician, AustinMember, Texas Medical Association (TMA) Committee on generic daily cialis online Child and Adolescent HealthExecutive Board Member, Texas Pediatric SocietyDoctors are community leaders. This role has become even more important during the erectile dysfunction treatment cialis. As patients navigate our new reality, generic daily cialis online they are looking to us to determine what is safe, how to protect their families, and the future of their health care.

As more Texans lose their jobs, their health insurance, or even their homes, it is crucial that Texas receives the resources it needs to uphold our social safety net. The U.S. Census helps determine funding for those resources, and that is why it is of the upmost importance that generic daily cialis online each and every Texan, no matter address, immigration status, or age, respond to the 2020 U.S.

Census. The deadline has been cut short one month generic daily cialis online and now closes Sept. 30.erectile dysfunction treatment has only increased the importance of completing the census to help our local communities and economies recover.

The novel erectile dysfunction has inflicted unprecedented strain on patients and exacerbated inequality as more people are out of work and are many in need of help with food, health care, housing, and more. Schools also have been stretched thin, with generic daily cialis online teachers scrambling to teach students online. Yet, the amount of federal funding Texas has available today to help weather this emergency was driven in part by the census responses made a decade ago.

Getting an accurate count in 2020 will help Texans prepare for the decade to follow, the first few years of which most certainly will be spent rebuilding from the cialis’s fallout. Therefore, it is vital that all Texans be counted.The federal dollars generic daily cialis online Texas receives generally depends on our population. A George Washington University study recently found that even a 1% undercount can lead to a $300 million loss in funding.Take Medicaid, for example.

Federal funds pay for 60% of the state’s program, which provides health coverage for generic daily cialis online two out of five Texas children, one in three individuals with disabilities, and 53% of all births. The complicated formula used to calculate the federal portion of this funding depends on accurate census data. If Texas’ population is undercounted, Texans may appear better off financially than they really are, resulting in Texas getting fewer federal Medicaid dollars.

If that happens, lawmakers will have to make up the difference, with cuts in services, program eligibility, or physician and provider payments, any of which are potentially detrimental.The census data also is key to funding other aspects of a generic daily cialis online community’s social safety net:Health careThe Children’s Health Insurance Program (CHIP) provides low-cost health insurance to children whose parents make too much to qualify for Medicaid, but not enough to afford quality coverage. Like Medicaid, how much money the federal government reimburses the state for the program depends in part on the census.Maternal and child health programs that promote public health and help ensure children are vaccinated relies on data from the census. Texas also generic daily cialis online uses this federal funding to study and respond to maternal mortality and perinatal depression.Food and housing As unemployment rises and families struggle financially, many live with uncertainty as to where they will find their next meal.

Already, one in seven Texans experiences food insecurity, and 20% of Texas children experience hunger. Food insecurity is rising in Texas as the cialis continues. The Central Texas Food generic daily cialis online Bank saw a 206% rise in clients in March.

Funding for the Supplemental Nutrition Assistance Program and school lunch programs are both determined by the census. Funding for local housing programs also is calculated via the census. An accurate count will help ensure that people who lose their homes during this economic crisis have better hope of finding generic daily cialis online shelter while our communities recover.

Homelessness is closely connected with declines in overall physical and mental health.Childcare and educationAs we navigate the new reality brought on by erectile dysfunction, more parents are taking on roles as breadwinner, parent, teacher, and caretaker. This stress highlights the desperate generic daily cialis online need for affordable childcare. The census determines funding for programs like Head Start that provide comprehensive early childhood education to low-income families.

The good news is you still have time to complete the census. Visit 2020census.gov to take generic daily cialis online it. It takes less than five minutes to complete.

Then talk to your family, neighbors, and colleagues about doing generic daily cialis online the same. If you are wondering who counts, the answer is everyone, whether it’s a newborn baby, child in foster care, undocumented immigrant, or an individual experiencing homelessness.Completing the census is one of the best things that you can do for the health of your community, especially during the cialis. Thank you for helping Texas heal and for supporting these essential safety net programs.(L to R).

UTHSA medical students Swetha Maddipudi, Brittany Hansen, Charles Wang, Carson Cortino, faculty advisor Kaparaboyna Kumar, generic daily cialis online MD, Ryan Wealther, Sidney Akabogu, Irma Ruiz, and Frank Jung pose with the TMA Be Wise Immunize banner. Photo courtesy by Ryan WealtherRyan WealtherMedical Student, UT Health San Antonio Long School of MedicineStudent Member, Texas Medical AssociationEditor’s Note. August is National Immunization Awareness Month.

This article is part of generic daily cialis online a Me&My Doctor series highlighting and promoting the use of vaccinations.“Can the flu shot give you the flu?. €â€œIs it dangerous for pregnant women to get a flu shot?. €â€œCan treatments cause generic daily cialis online autism?.

€These were questions women at Alpha Home, a residential substance abuse rehabilitation center in San Antonio, asked my fellow medical students and me during a flu treatment discussion. It is easy to see why these questions were asked, as treatment misinformation is common today.UTHSA medical student Frank Jing (left) gets a treatment fromKaparaboyna Kumar, MD, (right).Photo courtesy of Ryan Wealther“No” is the answer to all the questions. These were exactly the types of myths we set out to dispel at our vaccination drive.UT Health San Antonio Long School of Medicine medical students (under the supervision of Kaparaboyna Ashok Kumar, MD, faculty advisor for the Texas Medical Association Medical Student Section at UT Health San Antonio) hosted the treatment drive at Alpha Home with the support of TMA’s Be Wise – Immunize℠ program, a public health initiative that aims to increase generic daily cialis online vaccinations and treatment awareness through shot clinics and education.

Our program consisted of a vaccination drive and an interactive, educational presentation that addressed influenza, common flu shot questions, and general treatment myths. The Alpha Home residents could ask us questions during the program.We generic daily cialis online were interested to see if our educational program could answer Alpha Home residents’ questions about vaccinations and allay their hesitations about getting a flu vaccination. To gauge this, we created a brief survey.(Before I discuss the results of the survey, I should define treatment hesitancy.

treatment hesitancy is a concept defined by the World Health Organization. It relates to when patients do not vaccinate despite having access generic daily cialis online to treatments. treatment hesitancy is a problem because it prevents individuals from receiving their vaccinations.

That makes them more susceptible to getting sick from treatment-preventable diseases.)We surveyed the residents’ opinions about vaccinations before and after our educational program. While opinions about generic daily cialis online shots improved with each survey question, we saw the most significant attitude change reflected in answers to the questions “I am concerned that vaccinations might not be safe,” and “How likely are you to receive a flu shot today?. € We had informed the residents and improved their understanding and acceptance of immunizations.Post-survey results show more residents at the Alpha Home shifted to more positive attitudes about treatments, after learning more about their effectiveness by trusted members of the medical community.

Graph by Ryan WealtherWhy is this generic daily cialis online important?. First, our findings confirm what we already knew. Education by a trusted member of the medical community can effect change.

In fact, it is widely known that physician generic daily cialis online recommendation of vaccination is one of the most critical factors affecting whether patients receive an influenza vaccination. Perhaps some added proof to this is that a few of the Alpha Home residents were calling me “Dr. Truth” by the end of the evening.Second, our findings generic daily cialis online add to our understanding of adult treatment hesitancy.

This is significant because most of what we know about treatment hesitancy is limited to parental attitudes toward their children’s vaccinations. Some parents question shots for their children, and many of the most deadly diseases we vaccinate against are given in childhood, including polio, tetanus, measles, and whooping cough shots. However, adults need some vaccinations as generic daily cialis online well, like the yearly influenza treatment.

After taking part in the UTHSA educational program, more residents at the Alpha Home shared more willingness to receive the flu treatment. Graph by Ryan WealtherAnother reason improving attitudes is important is that receiving a flu shot is even more timely during the erectile dysfunction treatment cialis because it decreases illnesses and conserves health care resources. Thousands of people each year are hospitalized from the flu, and with hospitals filling up with erectile dysfunction patients, we could avoid adding dangerously ill generic daily cialis online flu patients to the mix.

Lastly, these findings are important because once a erectile dysfunction treatment vaccination becomes available, more people might be willing to receive it if their overall attitude toward immunizations is positive. Though the erectile dysfunction treatment is still in development, generic daily cialis online it is not immune to treatment hesitancy. Recent polls have indicated up to one-third of Americans would not receive a erectile dysfunction treatment even if it were accessible and affordable.

Work is already being done to try to raise awareness and acceptance. In addition, misinformation about the erectile dysfunction treatment is circulating generic daily cialis online widely. (Someone recently asked me if the erectile dysfunction treatment will implant a microchip in people, and I have seen the same myth circulating on social media.

It will not.) This myth, however, illustrates the need for health care professionals to answer patients’ questions and to assuage their generic daily cialis online concerns.treatments work best when many people in a community receive them, and treatment hesitancy can diminish vaccination rates, leaving people who can't get certain treatments susceptible to these treatment-preventable diseases. For example, babies under 6 months of age should not receive a flu shot, so high community vaccination rates protect these babies from getting sick with the flu. Our educational program at Alpha Home is just one example of how health care professionals can increase awareness and acceptance of shots.

As the erectile dysfunction treatment cialis progresses, we need to ensure children and adults receive their vaccinations as recommended by their physician and the Centers for Disease Control and generic daily cialis online Prevention. I encourage readers who have questions about the vaccinations they or their child may need to talk with their physician. As health care professionals, we’re more than happy to answer your questions..

Cialis pas cher

Patients are more likely to experience preventable harm during perioperative care than in any other type of healthcare encounter.1 2 For several decades, a hallmark of surgical quality and safety has been the use of cialis pas cher checklists to prevent errors (eg, wrong site surgery) and assure that key tasks have been or will be performed. The most widely used cialis pas cher approach globally is the Surgical Safety Checklist (SSC) recommended by the WHO.3 It is divided into preinduction (or sign in, consisting of seven items performed by anaesthesia and nursing), preincision (timeout, 10 items performed by the entire team) and postsurgery (sign out, five items by the entire team).4 5 Most hospitals in the developed world perform the SSC or an equivalent timeout prior to surgical incision. However, preinduction briefings, and postcase debriefings in particular, are much less commonly performed.6 7There are widely disseminated arguments recommending the use of checklists in healthcare8 but also recognised limitations.9 Checklist-based preincision timeouts appear to improve surgical outcomes in many settings,4 5 yet, in other hospitals, the introduction of the SSC failed to improve outcomes.10 Like all tools or processes intended to improve safety, ineffective implementation will reduce the desired benefits. For example, there is appreciable evidence showing that surgical teams skip or do not meaningfully respond to timeout checklist items.11 12 Even with a robust implementation, effectiveness can be weakened by contextual factors, failure of leadership or deficient safety culture.Despite numerous studies, gaps in the evidence to guide optimal checklist use cialis pas cher persist. For example, we do not know whether checklist-based timeouts only decrease the occurrence of the undesirable events targeted by the checklist or, as many hypothesise, whether their use also facilitates teamwork and interprofessional communication.

Although there is increasing guidance on how to optimally implement checklists at the local level, many questions remain.13 Moreover, we still do not understand the circumstances in which checklist use facilitates the detection, reporting and correction of errors.In this issue of cialis pas cher the journal, Muensterer and colleagues14 describe a clever study in which the attending surgeon intentionally introduced errors during the preincision timeout while a medical student in the operating theatre surreptitiously noted whether the error was detected and reported by one or more members of the surgical team. If the error was not verbalised, the attending surgeon corrected the error before the timeout was complete. The single error embedded in each of 120 of cialis pas cher 1800 paediatric operations was randomly chosen from among wrong patient name, age, gender, allergy or surgical procedure, side or site. Overall, only about half (65. 54%) of all errors were detected and reported by cialis pas cher a team member prior to surgeon correction.

Of these, errors were most commonly reported by the anaesthesiologist (64%) and almost never by residents in training (6%) or medical students (1%).This study also has important limitations. Because the investigators were leading the timeouts as part of a cialis pas cher research study, adherence to all of the checklist items was reportedly 100%. Yet, few organisations consistently attain timeout adherence above 90%.11 Since you are less likely to catch an error if you do not address that item during the timeout, in institutions with lower adherence, the proportion of missed errors may be even higher.The authors, with input from their institutional review board, designed the study to be feasible and compliant with established human subjects protection principles. As such, the attending surgeon always corrected the error after the anaesthesiologist’s cialis pas cher component of the timeout but before the nurses’ component. By excluding the part of the timeout when the nurses address their checklist items (eg, instruments are sterile,) followed by a final opportunity as the timeout ends to note any errors or concerns, the study may have underestimated the rate of error reporting.Because the study did not query team members individually after the timeout, we also do not know how many errors were detected but not annunciated.

For example, recognised errors that were cialis pas cher attributed to ‘misspeaking’ and/or had no clinical significance may not have been verbally challenged. Moreover, as is discussed by the authors, there was an unequivocal hierarchy effect—individuals with the least ‘power’ (ie, low in hierarchy within the current healthcare culture) were the least likely to report the error.This study highlights two important safety relevant questions on which I will elaborate. First, why and how should we cialis pas cher change healthcare culture to facilitate ‘speaking up’?. Second, how can we best design and implement checklists and other safety interventions to yield more consistent and sustained clinician behaviour change?. The continued problem of hierarchical culture in healthcareThe significant influence of hierarchy on the incidence of error reporting in Muensterer et al’s14 study is consistent with substantial prior evidence that cialis pas cher lower hierarchy clinical providers are less likely to ‘speak up’, even when they are aware of major safety violations.15–17Failure of a subordinate copilot to challenge or speak up to the captain in the 1977 Tenerife disaster was the impetus for the aviation industry’s adoption of crew resource management (CRM).

Healthcare team-training initiatives like the Agency for Healthcare Research and Quality’s TeamSTEPPS now include tools such as the ‘two-challenge rule’ and emphasise speaking up.18 Flattened hierarchies and reliance on expertise rather than seniority, especially during crisis or stress, are an integral component of high-reliability organisations. In contrast, the persistent hierarchical culture of healthcare is cialis pas cher anathema to positive safety attitudes and behaviours. This is particularly problematic in operating theatres where surgeons view themselves as ‘captain of the ship’ and where uncivil behaviour is tolerated.19 The insidious effects of hierarchy will impair effectiveness of checklist use and predispose to safety issues in all aspects of routine and emergency care.20 While team-oriented training designed to enhance the ability of lower hierarchy clinicians to ‘speak up’ can be effective,21 22 evidence to guide the design and implementation of these interventions is still sparse. Single training exposures have generally had limited effects,17 23 in part likely due to inadequate ‘potency’ to cialis pas cher achieve the desired effect24 in a clinical environment contaminated by the hierarchical culture and in part because most interventions have focused on ‘assertiveness’ training for the less powerful members of the team rather than, or in addition to, sensitivity or receptivity training of the most powerful (eg, surgical attendings).17Discussions of power hierarchy to date have largely focused on clinicians’ professional roles (ie, nurse vs physician) and level of experience (eg, resident vs attending). Even with two attending physicians, for example, a surgeon and anaesthesiologist, power dynamics can degrade communication and decrease team performance.

In a multicentre study of experienced anaesthesiologists managing simulated crisis events, the anaesthesiologists’ failure to challenge the surgeon to initiate life-saving interventions (eg, to open the abdomen cialis pas cher in the presence of an enlarging retroperitoneal haematoma during laparoscopic surgery, or to halt surgery to cardiovert an unstable patient) was associated with lower overall scenario performance scores as determined by trained blinded anaesthesiologist video raters.25In fact, hierarchy is much more complex and this may explain in part the variable and generally weak results seen in ‘speaking up’ intervention studies to date. When considering hierarchical effects on communication assertiveness, one must also consider individual characteristics including gender, race/ethnicity, language, personal cultural background and personality, as well as the personality of those in higher power roles, microclimate factors of the team and care unit, and overall organisational culture.17 22 An interesting direction for future study is the facilitation of more positive communication (eg, expressions of gratitude or encouragement).26In a single-site intervention study to improve the quality of handovers from anaesthesia professionals to postanaesthesia care unit (PACU) nurses,27 simulation-based training emphasised specific dyadic communication behaviours—assertiveness for the nurses when their needs were not being met and ‘sensitivity’ (or receptiveness) for the anaesthesia professionals when the nurses raised concerns. In poststudy interviews, this behavioural focus was considered an important cialis pas cher contributor to the resulting sustained improvement in the quality of actual handovers. As part of this study, we explicitly taught participants to CUSS. CUSS is cialis pas cher a graduated approach to facilitate speaking up.

The acronym stands for ‘I’m Concerned’, ‘I’m Uncomfortable’, ‘This is a Safety issue’ and ‘Stop!. €™. The intended learners were taught these ‘triggers’ for eliciting desired behaviours (ie, to stop what they are doing and have a conversation with the initiator) and this approach creates an environment where the initiating individual can receive support from others who overhear the conversation—‘Doctor, I hear that Maria is CUSSing at you?. How can I help to resolve this situation?. €™ Such a graded assertiveness approach to ‘stop the line’, developed in other industries, is increasingly being used throughout healthcare.28Designing and implementing more effective safety tools and processesSSCs are just one tool used to advance overall perioperative system safety.

Similarly, in commercial aviation, checklists are one tool used as part of CRM to assure operational safety. CRM is a philosophy or construct that includes explicit values and principles, procedures supported by purpose-designed checklists and other tools, and regularly scheduled mandatory simulation-based training and assessment that together contribute to an existing safety culture in pilots and across the organisation.29 CRM and most of the existing aviation safety system were iteratively designed by pilots (the front-line workers) in collaboration with other stakeholders (including regulators). Healthcare must employ similar human-centred design approaches to re-engineer our safety systems.For commercial aviation to be completely safe, no planes would fly. Similarly, safety will never be the foremost system objective in healthcare. The primary goal is to efficiently deliver cost-effective care.

Instead, in any high-consequence industry, safety is a desirable by-product (an ‘emergent feature’) of a system designed to achieve primary operational goals. In healthcare, sick patients must be treated and there is inherent risk in doing so.30 Achieving societally acceptable levels of safety will stem from a deliberately designed system founded on a strong safety culture and truly committed leadership.With this as background, it is not surprising that so many hospitals struggle to garner reliable and sustained benefit from the use of checklists and other safety tools. To understand what is required, I would like to draw parallels with anaesthesiology’s experience of implementing another type of checklist.The Food and Drug Administration Anesthesia Machine Pre-Use ChecklistThe earliest checklist used in healthcare to reduce adverse events is the anaesthesia equipment preuse checklist, developed in 1987 by the US Food and Drug Administration (FDA) in collaboration with the Anesthesia Patient Safety Foundation and the American Society of Anesthesiologists.31 After more than three decades of use, lessons learnt from the use of the FDA checklist parallel more recent experiences with SSCs, and are instructive to a more general understanding of the role of safety tools in healthcare (see table 1).View this table:Table 1 Lessons learnt from 30 years of personal experience with and reflection about the Anesthesia Equipment Pre-Use Checklist*A checklist alone is insufficient to achieve optimal resultsHospitals that get the best results from an SSC implementation are often well-resourced organisations that already have safety-oriented committed leadership, a strong safety culture, educated and engaged front-line clinicians and an established track record of successfully implementing other safety interventions.32 That said, any hospital, given adequate commitment, resources and expertise, can implement an SSC or other substantive safety intervention successfully. In doing so, it will educate and engage its workers, improve its safety culture and set the stage for further safety and quality improvements.A multimodal approach to safety interventions is more effective. Hospitals that were able to successfully implement all three components of the SSC saw greater reductions in postoperative complications.33 Similarly, the combination of the SSC with a complementary approach that more fully addresses preoperative and postoperative issues, the Surgical Patient Safety System, was associated with better postoperative outcomes than use of the WHO SSC alone.34 The most effective interventions are those that are based on an integrated conceptual framework and follow human factor principles, especially when the safety goals are multiple or diverse.35In our PACU handover improvement project mentioned earlier,27 the multimodal intervention produced a fourfold improvement in observed clinician behaviours (ie, conduct of actual handovers) that was sustained for at least 3 years after the intervention ceased.

The project began by getting perioperative leadership buy-in, conducting observations of the current handover process and engaging front-line clinicians in all phases of study development. The criteria for an ‘acceptable handover’ were chosen by an independent team of clinicians. Front-line clinicians first completed a multimedia introductory webinar that included key principles and a knowledge assessment. To attend the 2-hour simulation training session, both anaesthesia professionals and PACU nurses were relieved from regular clinical duties (a strong message that this was an organisational priority). A custom patient-specific electronic form was available at every bedside in the PACU to reinforce the training during actual handovers.

Performance feedback was provided to individuals, units and perioperative leadership. The number of components needed for successful safety interventions will depend on the behaviour change desired, the existing safety culture, current experience and expertise of the intended end users and the priority articulated by organisational leaders. Regardless, design and implementation must be based on a solid conceptual framework, consider the full life-cycle of the intervention (from conceptualisation to obsolescence) and employ human factors engineering and implementation science principles and tools.13ConclusionChecklists and other safety tools are potentially valuable tools to advance perioperative safety. However, when used in isolation or implemented incorrectly, checklists have significant limitations. Safety initiatives that take a systems-oriented multimodal approach to design and implementation can, with organisational leadership and determination, produce both targeted and more general safety improvement.Ethics statementsPatient consent for publicationNot required.Many patients admitted to hospital require venous access to infuse medications and fluids.

The most commonly used device, the peripheral venous catheter, ranges from 2.5 to 4.5 cm in length, and is typically used for less than 5 days. The midline, a relatively newer peripheral venous catheter, is up to 20 cm in length, but does not reach the central veins, and may be used for up to 2 weeks. A peripherally inserted central venous catheter (PICC) is a longer catheter that is placed in one of the arm veins and extends to reach the central veins. The PICC is used for longer periods of time compared with peripheral intravenous devices, and initially gained popularity as a convenient vascular access device used in the outpatient and home settings. Its premise has been to provide access that lasts for weeks, that is fairly safe and easily manageable.

Patients often require central venous access when hospitalised, with more than half of patients in intensive care, and up to 20% in those cared for in the non-intensive care wards.1 Common indications for PICC use in the acute care setting include the requirement for multiple and frequent infusions (eg, antibiotics, parenteral nutrition), the administration of medications incompatible with peripheral infusion, invasive haemodynamic monitoring in critically ill patients, very poor venous access and frequent need for blood draws.2 Specially trained healthcare workers place PICCs, often nurses from a vascular access team (VAT), or interventional radiologists. The VAT is comprised of skilled nurses, with either medical/surgical, emergency department or intensive care unit backgrounds. Contrary to other healthcare workers that place PICCs, the VAT’s primary function is to place PICCs, and optimise the infusion delivery, through a safe and effective process. Its scope includes assessment for need, peripheral and central device insertion, monitoring of use and removal.3In their study of five hospitals within the Veterans Administration (VA) healthcare systems in the USA, Krein et al4 underscore the importance of a formal VAT to formulate and implement explicit appropriateness criteria, ensure timely insertion and safe management and direct patient education around PICC use. They found that team structures supporting line placement vary across hospitals from a dedicated team, to individual nurses trained in placement, to hospitals where only interventional radiologists insert PICCs.

The presence of a VAT was associated with more defined criteria for PICC use, but a recurrent theme was inadequate interdisciplinary dialogue. Although qualitative data were gathered at five VA hospitals only, the study’s findings reflect the variation in PICC placement and use, whether in academic or community, small or large hospitals.An important factor in variation in the approach to PICC line placement and management is the availability of resources and expertise at the hospital site. For example, if healthcare workers have suboptimal skills to place peripheral venous catheters, including midlines,5 clinicians may resort to ordering more PICCs unnecessarily to fill that void. Furthermore, as revealed in Krein’s study, a hospital that does not have the expertise to learn about alternative devices, such as those with lower risks and shorter dwell times (eg, midlines), may resort to using more PICCs than necessary. Similarly, hospitals without clinicians skilled or comfortable placing other central lines6 may rely more on using PICCs.

In addition, the lack of an available VAT to place PICCs using uasound guidance may result in more referrals to interventional radiology for placement, potentially exposing the patient to avoidable radiation during fluoroscopy.7We propose an approach to improve the appropriate and safe use of PICCs by focusing on three elements that address the findings by Krein and colleagues. Establishing a structure powered by a VAT. Anchoring a standardised process for line selection, insertion and care. And promoting adoption by engagement with the key stakeholders.Establishing a structure to support placement and management of PICCs depends on whether the number of devices placed is enough to support the creation of a dedicated vascular access programme. Leadership plays a critical role to invest the resources for a functional VAT, understanding the financial and quality benefits associated.8 Not realising its value, hospital leaders may view the VAT as a non-revenue-generating service, putting it at risk when considering cost reduction strategies.

The value of the VAT expands from mitigating preventable events (eg, deep venous thrombosis, ) to enhancing patient experience (eg, less attempts to place a peripheral device).9 In addition, better outcomes help curb the financial risks (eg, hospital-acquired condition penalties)8 and improve hospital ratings. The VAT’s role encompasses placing PICCs and guaranteeing the proper selection of the intravascular device and its appropriate use.2The second element involves standardising processes for line selection and care, regardless of who is taking care of the device. Implementing policies to address indications, placement and maintenance and using standardised kits help minimise variation. The creation of policies should be achieved through a multidisciplinary approach with VAT, nurses and physicians. The VAT can act as the ‘gate keeper’ evaluating whether the reason for PICC placement is aligned with indications.

In addition, the VAT plays a critical role supporting nurses’ competencies for venous catheter use (eg, aseptic access and maintenance, addressing complications and mitigating risk)10 to reduce mechanical11 and infectious complications.12 The VAT performs regular rounds to mitigate process gaps (eg, dressing site intactness) and to identify complications (eg, PICC site erythema or drainage, arm swelling), and provides timely feedback on clinical performance. The VAT can also serve as subject matter experts to the ordering physicians for the appropriate device type, based on vessel size and indications for use, how many lumens, site selection and a de-escalation plan for the patient prior to discharge. It also provides services should a device-related complication occur (eg, clotting), and works with clinicians to remedy the issue and salvage the device, thereby preventing a patient from losing their vascular access and/or having to replace it.The last element, and perhaps most significant, is to enhance the adoption of best practices through a partnership with the key stakeholders. PICC-associated outcomes are not only owned by the VAT, rather it is the responsibility of the clinicians, physicians and nurses to achieve those goals (table 1). Physicians are an essential stakeholder group to engage as they are the ones responsible for ordering the PICC.

An identified physician champion who partners and empowers the VAT will help resolve any barriers and be a liaison with the local physician community.13 The ideal physician champion should have the respect of peers, understand process optimisation and promote quality improvement. They need to be well versed on the appropriate indications for PICC use, the associated complications and risks and alternatives to the device. The physician champion engages the leaders of the key disciplines responsible for requesting a PICC, educating them on the appropriate indications for use, the outcomes associated with PICC use, inviting them to be partners and responding to any of their concerns.View this table:Table 1 Disciplines and their support to mitigate PICC harmWhat about the key physician disciplines to engage?. Physicians can play an active role in enhancing PICC use through avoiding the unnecessary use of infusions. The consultation of infectious diseases specialists for intravenous antibiotic use appropriateness has been associated with less PICC use and lower complications.14 Similarly, having a surgeon support the decision for whether enteral or parenteral nutrition is needed will help reduce unnecessary device use.15 Disciplines like hospitalists or general internists care for a large number of patients and often order PICCs for venous access,16 while nephrologists may advocate avoiding the use of PICCs in the chronic kidney disease population in an effort for vein preservation.17 In hospitals with teaching programmes, the VAT and its physician champion may educate physicians in training on device choice, placement and duration of use, and address with their faculty competencies for line management.18 Engaging these disciplines, elucidating the indications for appropriate use and providing feedback and local data on the potential harm ensure accountability and further attention to PICC safety.In summary, the PICC is one of the primary solutions to achieve vascular access.

With up to one in five patients at risk for developing complications,19 it is incumbent on us to ensure that these devices are properly used and maintained. Identifying and overcoming system barriers are key to delivering sustainable safe outcomes. As a first step, clinical and administrative leaders, realising the financial and quality benefits, need to support the structure reflected by the VAT to enhance PICC care. Second, the VAT must partner with disciplines (particularly nursing) to promote and ensure adequate competencies for placement and maintenance. Finally, clinical disciplines caring for the patient should instil a collaborative environment for better decision-making on when central access is required, and what device provides the safest and most effective delivery of care.Ethics statementsPatient consent for publicationNot required..

Patients are more likely to experience preventable harm during perioperative care than in any other type of healthcare encounter.1 2 For buy cialis pill several decades, a hallmark of surgical quality and safety has been the use of checklists to prevent generic daily cialis online errors (eg, wrong site surgery) and assure that key tasks have been or will be performed. The most widely used approach globally is the Surgical Safety Checklist (SSC) recommended by the WHO.3 It is divided into preinduction (or sign in, consisting of seven items performed by anaesthesia and nursing), preincision (timeout, 10 items performed by the entire team) and postsurgery (sign out, five items by the entire team).4 5 Most hospitals in generic daily cialis online the developed world perform the SSC or an equivalent timeout prior to surgical incision. However, preinduction briefings, and postcase debriefings in particular, are much less commonly performed.6 7There are widely disseminated arguments recommending the use of checklists in healthcare8 but also recognised limitations.9 Checklist-based preincision timeouts appear to improve surgical outcomes in many settings,4 5 yet, in other hospitals, the introduction of the SSC failed to improve outcomes.10 Like all tools or processes intended to improve safety, ineffective implementation will reduce the desired benefits.

For example, there is appreciable evidence showing that surgical teams skip or do not meaningfully respond to timeout checklist items.11 12 Even with a robust implementation, effectiveness can be weakened by contextual factors, failure of leadership or deficient safety generic daily cialis online culture.Despite numerous studies, gaps in the evidence to guide optimal checklist use persist. For example, we do not know whether checklist-based timeouts only decrease the occurrence of the undesirable events targeted by the checklist or, as many hypothesise, whether their use also facilitates teamwork and interprofessional communication. Although there is increasing guidance on how to optimally implement checklists at the local level, many questions remain.13 Moreover, we still do not understand the circumstances in which checklist use facilitates the detection, reporting and correction of errors.In this issue of the journal, Muensterer and colleagues14 describe a clever study in which the attending surgeon intentionally introduced errors during the preincision timeout while a medical student in the operating theatre surreptitiously noted whether the error was detected and reported by one or more generic daily cialis online members of the surgical team.

If the error was not verbalised, the attending surgeon corrected the error before the timeout was complete. The single error embedded in each of 120 of 1800 paediatric operations was randomly generic daily cialis online chosen from among wrong patient name, age, gender, allergy or surgical procedure, side or site. Overall, only about half (65.

54%) of generic daily cialis online all errors were detected and reported by a team member prior to surgeon correction. Of these, errors were most commonly reported by the anaesthesiologist (64%) and almost never by residents in training (6%) or medical students (1%).This study also has important limitations. Because the investigators were leading the timeouts as part of a research study, adherence to all generic daily cialis online of the checklist items was reportedly 100%.

Yet, few organisations consistently attain timeout adherence above 90%.11 Since you are less likely to catch an error if you do not address that item during the timeout, in institutions with lower adherence, the proportion of missed errors may be even higher.The authors, with input from their institutional review board, designed the study to be feasible and compliant with established human subjects protection principles. As such, generic daily cialis online the attending surgeon always corrected the error after the anaesthesiologist’s component of the timeout but before the nurses’ component. By excluding the part of the timeout when the nurses address their checklist items (eg, instruments are sterile,) followed by a final opportunity as the timeout ends to note any errors or concerns, the study may have underestimated the rate of error reporting.Because the study did not query team members individually after the timeout, we also do not know how many errors were detected but not annunciated.

For example, recognised errors that were attributed to ‘misspeaking’ and/or had no clinical significance may not have been verbally generic daily cialis online challenged. Moreover, as is discussed by the authors, there was an unequivocal hierarchy effect—individuals with the least ‘power’ (ie, low in hierarchy within the current healthcare culture) were the least likely to report the error.This study highlights two important safety relevant questions on which I will elaborate. First, why generic daily cialis online and how should we change healthcare culture to facilitate ‘speaking up’?.

Second, how can we best design and implement checklists and other safety interventions to yield more consistent and sustained clinician behaviour change?. The continued problem of hierarchical culture in healthcareThe significant influence of hierarchy on the incidence of error reporting in Muensterer et al’s14 study is consistent with substantial prior evidence that lower hierarchy clinical providers are less likely to ‘speak up’, even when they are aware of major safety generic daily cialis online violations.15–17Failure of a subordinate copilot to challenge or speak up to the captain in the 1977 Tenerife disaster was the impetus for the aviation industry’s adoption of crew resource management (CRM). Healthcare team-training initiatives like the Agency for Healthcare Research and Quality’s TeamSTEPPS now include tools such as the ‘two-challenge rule’ and emphasise speaking up.18 Flattened hierarchies and reliance on expertise rather than seniority, especially during crisis or stress, are an integral component of high-reliability organisations.

In contrast, the persistent hierarchical culture of healthcare is anathema to positive safety attitudes and generic daily cialis online behaviours. This is particularly problematic in operating theatres where surgeons view themselves as ‘captain of the ship’ and where uncivil behaviour is tolerated.19 The insidious effects of hierarchy will impair effectiveness of checklist use and predispose to safety issues in all aspects of routine and emergency care.20 While team-oriented training designed to enhance the ability of lower hierarchy clinicians to ‘speak up’ can be effective,21 22 evidence to guide the design and implementation of these interventions is still sparse. Single training exposures have generally had limited effects,17 23 in part likely due to inadequate ‘potency’ to achieve the desired effect24 in a clinical environment contaminated by the hierarchical culture and in part because most interventions have focused on ‘assertiveness’ generic daily cialis online training for the less powerful members of the team rather than, or in addition to, sensitivity or receptivity training of the most powerful (eg, surgical attendings).17Discussions of power hierarchy to date have largely focused on clinicians’ professional roles (ie, nurse vs physician) and level of experience (eg, resident vs attending).

Even with two attending physicians, for example, a surgeon and anaesthesiologist, power dynamics can degrade communication and decrease team performance. In a multicentre study of experienced anaesthesiologists managing simulated crisis events, the anaesthesiologists’ generic daily cialis online failure to challenge the surgeon to initiate life-saving interventions (eg, to open the abdomen in the presence of an enlarging retroperitoneal haematoma during laparoscopic surgery, or to halt surgery to cardiovert an unstable patient) was associated with lower overall scenario performance scores as determined by trained blinded anaesthesiologist video raters.25In fact, hierarchy is much more complex and this may explain in part the variable and generally weak results seen in ‘speaking up’ intervention studies to date. When considering hierarchical effects on communication assertiveness, one must also consider individual characteristics including gender, race/ethnicity, language, personal cultural background and personality, as well as the personality of those in higher power roles, microclimate factors of the team and care unit, and overall organisational culture.17 22 An interesting direction for future study is the facilitation of more positive communication (eg, expressions of gratitude or encouragement).26In a single-site intervention study to improve the quality of handovers from anaesthesia professionals to postanaesthesia care unit (PACU) nurses,27 simulation-based training emphasised specific dyadic communication behaviours—assertiveness for the nurses when their needs were not being met and ‘sensitivity’ (or receptiveness) for the anaesthesia professionals when the nurses raised concerns.

In poststudy interviews, this behavioural focus was considered an important contributor to the resulting sustained improvement generic daily cialis online in the quality of actual handovers. As part of this study, we explicitly taught participants to CUSS. CUSS is generic daily cialis online a graduated approach to facilitate speaking up.

The acronym stands for ‘I’m Concerned’, ‘I’m Uncomfortable’, ‘This is a Safety issue’ and ‘Stop!. €™. The intended learners were taught these ‘triggers’ for eliciting desired behaviours (ie, to stop what they are doing and have a conversation with the initiator) and this approach creates an environment where the initiating individual can receive support from others who overhear the conversation—‘Doctor, I hear that Maria is CUSSing at you?.

How can I help to resolve this situation?. €™ Such a graded assertiveness approach to ‘stop the line’, developed in other industries, is increasingly being used throughout healthcare.28Designing and implementing more effective safety tools and processesSSCs are just one tool used to advance overall perioperative system safety. Similarly, in commercial aviation, checklists are one tool used as part of CRM to assure operational safety.

CRM is a philosophy or construct that includes explicit values and principles, procedures supported by purpose-designed checklists and other tools, and regularly scheduled mandatory simulation-based training and assessment that together contribute to an existing safety culture in pilots and across the organisation.29 CRM and most of the existing aviation safety system were iteratively designed by pilots (the front-line workers) in collaboration with other stakeholders (including regulators). Healthcare must employ similar human-centred design approaches to re-engineer our safety systems.For commercial aviation to be completely safe, no planes would fly. Similarly, safety will never be the foremost system objective in healthcare.

The primary goal is to efficiently deliver cost-effective care. Instead, in any high-consequence industry, safety is a desirable by-product (an ‘emergent feature’) of a system designed to achieve primary operational goals. In healthcare, sick patients must be treated and there is inherent risk in doing so.30 Achieving societally acceptable levels of safety will stem from a deliberately designed system founded on a strong safety culture and truly committed leadership.With this as background, it is not surprising that so many hospitals struggle to garner reliable and sustained benefit from the use of checklists and other safety tools.

To understand what is required, I would like to draw parallels with anaesthesiology’s experience of implementing another type of checklist.The Food and Drug Administration Anesthesia Machine Pre-Use ChecklistThe earliest checklist used in healthcare to reduce adverse events is the anaesthesia equipment preuse checklist, developed in 1987 by the US Food and Drug Administration (FDA) in collaboration with the Anesthesia Patient Safety Foundation and the American Society of Anesthesiologists.31 After more than three decades of use, lessons learnt from the use of the FDA checklist parallel more recent experiences with SSCs, and are instructive to a more general understanding of the role of safety tools in healthcare (see table 1).View this table:Table 1 Lessons learnt from 30 years of personal experience with and reflection about the Anesthesia Equipment Pre-Use Checklist*A checklist alone is insufficient to achieve optimal resultsHospitals that get the best results from an SSC implementation are often well-resourced organisations that already have safety-oriented committed leadership, a strong safety culture, educated and engaged front-line clinicians and an established track record of successfully implementing other safety interventions.32 That said, any hospital, given adequate commitment, resources and expertise, can implement an SSC or other substantive safety intervention successfully. In doing so, it will educate and engage its workers, improve its safety culture and set the stage for further safety and quality improvements.A multimodal approach to safety interventions is more effective. Hospitals that were able to successfully implement all three components of the SSC saw greater reductions in postoperative complications.33 Similarly, the combination of the SSC with a complementary approach that more fully addresses preoperative and postoperative issues, the Surgical Patient Safety System, was associated with better postoperative outcomes than use of the WHO SSC alone.34 The most effective interventions are those that are based on an integrated conceptual framework and follow human factor principles, especially when the safety goals are multiple or diverse.35In our PACU handover improvement project mentioned earlier,27 the multimodal intervention produced a fourfold improvement in observed clinician behaviours (ie, conduct of actual handovers) that was sustained for at least 3 years after the intervention ceased.

The project began by getting perioperative leadership buy-in, conducting observations of the current handover process and engaging front-line clinicians in all phases of study development. The criteria for an ‘acceptable handover’ were chosen by an independent team of clinicians. Front-line clinicians first completed a multimedia introductory webinar that http://www.buxmontseniorservices.org/business-services-community-events included key principles and a knowledge assessment.

To attend the 2-hour simulation training session, both anaesthesia professionals and PACU nurses were relieved from regular clinical duties (a strong message that this was an organisational priority). A custom patient-specific electronic form was available at every bedside in the PACU to reinforce the training during actual handovers. Performance feedback was provided to individuals, units and perioperative leadership.

The number of components needed for successful safety interventions will depend on the behaviour change desired, the existing safety culture, current experience and expertise of the intended end users and the priority articulated by organisational leaders. Regardless, design and implementation must be based on a solid conceptual framework, consider the full life-cycle of the intervention (from conceptualisation to obsolescence) and employ human factors engineering and implementation science principles and tools.13ConclusionChecklists and other safety tools are potentially valuable tools to advance perioperative safety. However, when used in isolation or implemented incorrectly, checklists have significant limitations.

Safety initiatives that take a systems-oriented multimodal approach to design and implementation can, with organisational leadership and determination, produce both targeted and more general safety improvement.Ethics statementsPatient consent for publicationNot required.Many patients admitted to hospital require venous access to infuse medications and fluids. The most commonly used device, the peripheral venous catheter, ranges from 2.5 to 4.5 cm in length, and is typically used for less than 5 days. The midline, a relatively newer peripheral venous catheter, is up to 20 cm in length, but does not reach the central veins, and may be used for up to 2 weeks.

A peripherally inserted central venous catheter (PICC) is a longer catheter that is placed in one of the arm veins and extends to reach the central veins. The PICC is used for longer periods of time compared with peripheral intravenous devices, and initially gained popularity as a convenient vascular access device used in the outpatient and home settings. Its premise has been to provide access that lasts for weeks, that is fairly safe and easily manageable.

Patients often require central venous access when hospitalised, with more than half of patients in intensive care, and up to 20% in those cared for in the non-intensive care wards.1 Common indications for PICC use in the acute care setting include the requirement for multiple and frequent infusions (eg, antibiotics, parenteral nutrition), the administration of medications incompatible with peripheral infusion, invasive haemodynamic monitoring in critically ill patients, very poor venous access and frequent need for blood draws.2 Specially trained healthcare workers place PICCs, often nurses from a vascular access team (VAT), or interventional radiologists. The VAT is comprised of skilled nurses, with either medical/surgical, emergency department or intensive care unit backgrounds. Contrary to other healthcare workers that place PICCs, the VAT’s primary function is to place PICCs, and optimise the infusion delivery, through a safe and effective process.

Its scope includes assessment for need, peripheral and central device insertion, monitoring of use and removal.3In their study of five hospitals within the Veterans Administration (VA) healthcare systems in the USA, Krein et al4 underscore the importance of a formal VAT to formulate and implement explicit appropriateness criteria, ensure timely insertion and safe management and direct patient education around PICC use. They found that team structures supporting line placement vary across hospitals from a dedicated team, to individual nurses trained in placement, to hospitals where only interventional radiologists insert PICCs. The presence of a VAT was associated with more defined criteria for PICC use, but a recurrent theme was inadequate interdisciplinary dialogue.

Although qualitative data were gathered at five VA hospitals only, the study’s findings reflect the variation in PICC placement and use, whether in academic or community, small or large hospitals.An important factor in variation in the approach to PICC line placement and management is the availability of resources and expertise at the hospital site. For example, if healthcare workers have suboptimal skills to place peripheral venous catheters, including midlines,5 clinicians may resort to ordering more PICCs unnecessarily to fill that void. Furthermore, as revealed in Krein’s study, a hospital that does not have the expertise to learn about alternative devices, such as those with lower risks and shorter dwell times (eg, midlines), may resort to using more PICCs than necessary.

Similarly, hospitals without clinicians skilled or comfortable placing other central lines6 may rely more on using PICCs. In addition, the lack of an available VAT to place PICCs using uasound guidance may result in more referrals to interventional radiology for placement, potentially exposing the patient to avoidable radiation during fluoroscopy.7We propose an approach to improve the appropriate and safe use of PICCs by focusing on three elements that address the findings by Krein and colleagues. Establishing a structure powered by a VAT.

Anchoring a standardised process for line selection, insertion and care. And promoting adoption by engagement with the key stakeholders.Establishing a structure to support placement and management of PICCs depends on whether the number of devices placed is enough to support the creation of a dedicated vascular access programme. Leadership plays a critical role to invest the resources for a functional VAT, understanding the financial and quality benefits associated.8 Not realising its value, hospital leaders may view the VAT as a non-revenue-generating service, putting it at risk when considering cost reduction strategies.

The value of the VAT expands from mitigating preventable events (eg, deep venous thrombosis, ) to enhancing patient experience (eg, less attempts to place a peripheral device).9 In addition, better outcomes help curb the financial risks (eg, hospital-acquired condition penalties)8 and improve hospital ratings. The VAT’s role encompasses placing PICCs and guaranteeing the proper selection of the intravascular device and its appropriate use.2The second element involves standardising processes for line selection and care, regardless of who is taking care of the device. Implementing policies to address indications, placement and maintenance and using standardised kits help minimise variation.

The creation of policies should be achieved through a multidisciplinary approach with VAT, nurses and physicians. The VAT can act as the ‘gate keeper’ evaluating whether the reason for PICC placement is aligned with indications. In addition, the VAT plays a critical role supporting nurses’ competencies for venous catheter use (eg, aseptic access and maintenance, addressing complications and mitigating risk)10 to reduce mechanical11 and infectious complications.12 The VAT performs regular rounds to mitigate process gaps (eg, dressing site intactness) and to identify complications (eg, PICC site erythema or drainage, arm swelling), and provides timely feedback on clinical performance.

The VAT can also serve as subject matter experts to the ordering physicians for the appropriate device type, based on vessel size and indications for use, how many lumens, site selection and a de-escalation plan for the patient prior to discharge. It also provides services should a device-related complication occur (eg, clotting), and works with clinicians to remedy the issue and salvage the device, thereby preventing a patient from losing their vascular access and/or having to replace it.The last element, and perhaps most significant, is to enhance the adoption of best practices through a partnership with the key stakeholders. PICC-associated outcomes are not only owned by the VAT, rather it is the responsibility of the clinicians, physicians and nurses to achieve those goals (table 1).

Physicians are an essential stakeholder group to engage as they are the ones responsible for ordering the PICC. An identified physician champion who partners and empowers the VAT will help resolve any barriers and be a liaison with the local physician community.13 The ideal physician champion should have the respect of peers, understand process optimisation and promote quality improvement. They need to be well versed on the appropriate indications for PICC use, the associated complications and risks and alternatives to the device.

The physician champion engages the leaders of the key disciplines responsible for requesting a PICC, educating them on the appropriate indications for use, the outcomes associated with PICC use, inviting them to be partners and responding to any of their concerns.View this table:Table 1 Disciplines and their support to mitigate PICC harmWhat about the key physician disciplines to engage?. Physicians can play an active role in enhancing PICC use through avoiding the unnecessary use of infusions. The consultation of infectious diseases specialists for intravenous antibiotic use appropriateness has been associated with less PICC use and lower complications.14 Similarly, having a surgeon support the decision for whether enteral or parenteral nutrition is needed will help reduce unnecessary device use.15 Disciplines like hospitalists or general internists care for a large number of patients and often order PICCs for venous access,16 while nephrologists may advocate avoiding the use of PICCs in the chronic kidney disease population in an effort for vein preservation.17 In hospitals with teaching programmes, the VAT and its physician champion may educate physicians in training on device choice, placement and duration of use, and address with their faculty competencies for line management.18 Engaging these disciplines, elucidating the indications for appropriate use and providing feedback and local data on the potential harm ensure accountability and further attention to PICC safety.In summary, the PICC is one of the primary solutions to achieve vascular access.

With up to one in five patients at risk for developing complications,19 it is incumbent on us to ensure that these devices are properly used and maintained. Identifying and overcoming system barriers are key to delivering sustainable safe outcomes. As a first step, clinical and administrative leaders, realising the financial and quality benefits, need to support the structure reflected by the VAT to enhance PICC care.

Second, the VAT must partner with disciplines (particularly nursing) to promote and ensure adequate competencies for placement and maintenance. Finally, clinical disciplines caring for the patient should instil a collaborative environment for better decision-making on when central access is required, and what device provides the safest and most effective delivery of care.Ethics statementsPatient consent for publicationNot required..