BACKGROUND: Incorporating emerging knowledge into Emergency Medical Service (EMS) competency assessments is critical to reflect current evidence-based out-of-hospital care. However, a standardized approach is needed to incorporate new evidence into EMS competency assessments because of the rapid pace of knowledge generation.
OBJECTIVE: The objective was to develop a framework to evaluate and integrate new source material into EMS competency assessments.
METHODS: The National Registry of Emergency Medical Technicians (National Registry) and the Prehospital Guidelines Consortium (PGC) convened a panel of experts. A Delphi method, consisting of virtual meetings and electronic surveys, was used to develop a Table of Evidence matrix that defines sources of EMS evidence. In Round One, participants listed all potential sources of evidence available to inform EMS education. In Round Two, participants categorized these sources into: (a) levels of evidence quality; and (b) type of source material. In Round Three, the panel revised a proposed Table of Evidence. Finally, in Round Four, participants provided recommendations on how each source should be incorporated into competency assessments depending on type and quality. Descriptive statistics were calculated with qualitative analyses conducted by two independent reviewers and a third arbitrator.
RESULTS: In Round One, 24 sources of evidence were identified. In Round Two, these were classified into high- (n = 4), medium- (n = 15), and low-quality (n = 5) of evidence, followed by categorization by purpose into providing recommendations (n = 10), primary research (n = 7), and educational content (n = 7). In Round Three, the Table of Evidence was revised based on participant feedback. In Round Four, the panel developed a tiered system of evidence integration from immediate incorporation of high-quality sources to more stringent requirements for lower-quality sources.
CONCLUSIONS: The Table of Evidence provides a framework for the rapid and standardized incorporation of new source material into EMS competency assessments. Future goals are to evaluate the application of the Table of Evidence framework in initial and continued competency assessments.

BACKGROUND: The COVID-19 pandemic posed several challenges for surgical training, including the suspension of many in-person teaching sessions in lieu of webinars. As restrictions have eased, both prepandemic and postpandemic training methods should be used.
OBJECTIVE: This study investigates trainees\' experiences of webinars during the COVID-19 pandemic to develop recommendations for their effective integration into surgical training going forward.
METHODS: This project was led by the Association of Surgeons in Training and used an iterative process with mixed qualitative methods to consolidate arguments for and against webinars, and the drivers and barriers to their effective delivery, into recommendations. This involved 3 phases: (1) a web-based survey, (2) focus group interviews, and (3) a consensus session using a nominal group technique.
RESULTS: Trainees (N=281) from across specialties and grades confirmed that the COVID-19 pandemic led to an increase in webinars for surgical training. While there were concerns, particularly around the utility for practical training (80.9%), the majority agreed that webinars had a role in training following the COVID-19 pandemic (90.2%). The cited benefits included improved access or flexibility and potential standardization of training. The majority of limitations were technical. These perspectives were refined through focus group interviews (n=18) into 25 recommendations, 23 of which were ratified at a consensus meeting, which was held at the Association of Surgeons in Training 2021 conference.
CONCLUSIONS: Webinars have a role in surgical training following the COVID-19 pandemic. The 23 recommendations encompass indications and technical considerations but also discuss important knowledge gaps. They should serve as an initial framework for ensuring that webinars add value and continue to evolve as a tool for training.
BACKGROUND: Chinese Clinical Trial Registry ChiCTR2200055325; http://www.chictr.org.cn/showprojen.aspx?proj=142802.

UNASSIGNED: Patients worldwide experience fragmented and uncoordinated care as they transition between primary and acute care. To improve system integration and outcomes for patients, in 2017/2018 Alberta Health Services (largest health services delivery organization in Canada) called for a coordinated approach to improve transitions in care (TiC). Healthcare leadership responded by initiating the development of a province-wide guideline outlining core components of effective transitions in care. This case study highlights the extensive design process used to develop this guideline, with a focus on the participatory design (PD) approach used throughout.
UNASSIGNED: An iterative, mixed methods PD approach was used to engage over 750 stakeholders through the following activities to establish Guideline content: i) learning collaborative; ii) design-team; iii) targeted online surveys; iv) primary care stakeholder consultation; v) modified Delphi panel; and vi) patient advisory committee.
UNASSIGNED: The result was Alberta\'s first guideline for supporting patients through TiC: \"Alberta\'s Home to Hospital to Home Transitions Guideline\".
UNASSIGNED: The extensive design process used to create the Guideline was instrumental in establishing content, encouraging system integration, and creating conditions to support provincial implementation. While intended to improve and standardize patient care in Alberta, the methods used and lessons learned throughout the development of the Guideline are applicable internationally.

BACKGROUND: The Zambia Medicines Regulatory Authority (ZAMRA) piloted the implementation of Guidelines on Operating Health Shops in Zambia in 2016, with a view to making basic medicines more accessible to communities. The guidelines aim to transform ordinary drug shops into health shops, which are dispensing facilities permitted to sell a ZAMRA-prescribed list of medicines over the counter. However, studies that explore the integration and uptake of guidelines into the health system are lacking. This study aims to inform future improved implementation of these guidelines by examining the current acceptability of guidelines within the Zambian health system, especially in relation to family planning services.
METHODS: Data collected through documentary review, key informant interviews with district pharmacists, staff from ZAMRA and in-depth interviews with 24 health shop owners and dispensers were analyzed using thematic analysis. A conceptual framework on the integration of health innovations into health systems guided the analysis.
RESULTS: The Guidelines on Operating Health Shops were implemented to address the problem of inadequate access to quality medicines especially in rural areas. Factors that facilitated the acceptability of the guidelines included their perceived relevance and simplicity, comprehensive training and improved knowledge among health shop operators on the guidelines, development of a governance and reporting structure or steering committee at the national level as well as perceived improved health outcomes at the community level. Factors that hindered acceptability of the guidelines included the high cost of implementing them, a restricted list of drugs which affected consumer choice, limited communication between the local council and the operators of health shops, health shop owners not owning the health shop premises restricting their ability to adapt the building, and cultural norms which constrained uptake of family planning services.
CONCLUSIONS: In addition to training, facilitating the acceptability of the guidelines among health shop owners requires paying attention to operational issues such as location, ownership of the shop, size of infrastructure as well as financial costs of implementing guidelines through decentralizing the registration process and thus reducing the cost of registration. It is also important to have effective communication strategies between operators and the regulators of health shops.

BACKGROUND: Although HIV continues to have a high prevalence among adults in sub-Saharan Africa (SSA), the burden of noncommunicable diseases (NCD) such as diabetes and hypertension is increasing rapidly. There is an urgent need to expand the capacity of healthcare systems in SSA to provide NCD services and scale up existing chronic care management pathways. The aim of this study was to identify key components, outcomes, and best practice in integrated service provision for the prevention, identification and treatment of HIV, hypertension and diabetes.
METHODS: An international, multi stakeholder e-Delphi consensus study was conducted over two successive rounds. In Round 1, 24 participants were asked to score 27 statements, under the headings \'Service Provision\' and \'Benefits of Integration\', by importance. In Round 2, the 16 participants who completed Round 1 were shown the distribution of scores from other participants along with the score that they attributed to an outcome and were asked to reflect on the score they gave, based on the scores of the other participants and then to rescore if they wished to. Nine participants completed Round 2.
RESULTS: Based on the Round 1 ranking, 19 of the 27 outcomes met the 70% threshold for consensus. Four additional outcomes suggested by participants in Round 1 were added to Round 2, and upon review by participants, 22 of the 31 outcomes met the consensus threshold. The five items participants scored from 7 to 9 in both rounds as essential for effective integrated healthcare delivery of health services for chronic conditions were improved data collection and surveillance of NCDs among people living with HIV to inform integrated NCD/HIV programme management, strengthened drug procurement systems, availability of equipment and access to relevant blood tests, health education for all chronic conditions, and enhanced continuity of care for patients with multimorbidity.
CONCLUSIONS: This study highlights the outcomes which may form key components of future complex interventions to define a model of integrated healthcare delivery for diabetes, hypertension and HIV in sub-Saharan Africa.

Childhood obesity remains a serious public health threat. There is an urgent need for innovative, effective, and sustainable interventions for childhood obesity that are multisector, integrated, and pragmatic. Using the 2007 Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity as a guide, a tertiary care obesity program at a children\'s hospital established the Primary Care Obesity Network (PCON). This article describes the structure, implementation, resources, and outcome measures of the PCON, a network of primary care practices and a tertiary care obesity center established to prevent and treat childhood obesity in Central Ohio. This program offers an opportunity to assess how and whether the expert committee guidelines can be translated into practice. As Accountable Care Organizations strive to provide services through the lens of improving population health, the PCON can serve as an example for addressing childhood obesity.

Introduction: Childhood tuberculosis (TB) and undernutrition are major global public health challenges. In 2015, although an estimated 1 million children aged <15 years developed TB, the majority of the cases remain undiagnosed, partly due to a lack of awareness and capacity by providers who serve as the first point of care for sick children. This calls for better integration of TB with child health and nutrition services. TB can cause or worsen undernutrition, and undernutrition increases the risk of TB. Methods: Guidelines for the management of acute malnutrition from 17 high TB burden countries were reviewed to gather information on TB symptom screening, exposure history, and treatment. Results: Seven (41%) countries recommend routine TB screening among children with acute malnutrition, and six (35%) recommend obtaining a TB exposure history. Conclusion: TB screening is not consistently included in guidelines for acute malnutrition in high TB burden countries. Routine TB risk assessment, especially history of TB exposure, among acutely malnourished children, combined with improved linkages with TB services, would help increase TB case finding and could impact outcomes. Operational research on how best to integrate services at different levels of the health care system is needed.
Cadre: La tuberculose (TB) de l\'enfance et la malnutrition sont des défis majeurs de santé publique dans le monde. On estime qu\'un million d\'enfants âgés de <15 ans ont eu une TB en 2015, mais la majorité des cas sont restés non diagnostiqués, en partie à cause du manque de connaissance et de capacité des prestataires de soins qui sont le premier point de contact pour les enfants malades ; ceci demande une meilleure intégration de la TB avec les services de santé de l\'enfant et de nutrition. La TB peut causer ou aggraver la malnutrition et la malnutrition augmente le risque de TB.Methodes: Les directives pour la prise en charge de la malnutrition aiguë de 17 pays durement frappés par la TB ont été revues afin de rassembler des informations relatives au dépistage des symptômes de TB, des antécédents d\'exposition et de traitement.Résultats: Sept (41%) pays recommandent un dépistage de routine de la TB parmi les enfants ayant une malnutrition aiguë et six (35%) recommandent de rechercher des antécédents d\'exposition à la TB.Conclusion: Le dépistage de la TB n\'est pas systématiquement inclus dans les directives relatives à la malnutrition aiguë dans les pays durement frappés par la TB. Une évaluation de routine du risque de TB, particulièrement des antécédents d\'exposition à la TB, parmi les enfants atteints de malnutrition aiguë, combinée à de meilleurs liens avec les services de TB contribuerait à augmenter la découverte des cas de TB et améliorer leur évolution. Une recherche opérationnelle sur la meilleure façon d\'intégrer les services à différents niveaux du système de santé est nécessaire.
Marco de referencia: La tuberculosis (TB) durante la infancia y la desnutrición representan graves problemas de salud pública en el mundo. Se estima que un millón de niños de edad de <15 años contrajeron la TB en el 2015, pero la mayoría de los casos permaneció sin diagnóstico, debido en parte a la falta de sensibilización y a la escasa capacidad de los profesionales de salud que atienden en primera línea a los niños enfermos; esta situación exige una mejor integración de los servicios de atención de la TB y los servicios que se ocupan de la salud y la nutrición de los niños. La TB puede causar o agravar la desnutrición y esta a su vez aumenta el riesgo de contraer la TB.Métodos: Se analizaron las directrices de manejo de la desnutrición aguda de 17 países con alta carga de morbilidad por TB, con el objeto de reunir información sobre la detección sistemática de los síntomas, los antecedentes de exposición y el tratamiento de la TB.Resultados: Siete países recomendaban la detección sistemática de la TB en la práctica corriente en los niños con desnutrición aguda (41%) y seis países recomendaban obtener los antecedentes de exposición a la enfermedad (35%).Conclusión: La recomendación de la detección sistemática de la TB no es constante en las directrices de manejo de la desnutrición en los países con alta carga de morbilidad por esta enfermedad. La práctica corriente de una evaluación del riesgo de TB, sobre todo de los antecedentes de exposición en los niños aquejados de desnutrición aguda, aunada a mejores vínculos con los servicios de atención de la TB contribuiría a aumentar el rendimiento de la búsqueda de casos y mejorar los desenlaces. Sería muy útil realizar investigaciones operativas sobre la mejor manera de integrar los servicios en los diferentes niveles del sistema de atención de salud.

International associations admit that specialized palliative care (SPC) is an obvious component of excellent cancer care. Nevertheless, gaps in integration at the international level have been identified. Recommendations for integrating SPC in clinical care, research, and education are needed, which are subject of the present study.
A Delphi study, with three written Delphi rounds, including a face-to-face-meeting with a multiprofessional expert panel (n = 52) working in SPC in 15 German Comprehensive Cancer Centers (CCCs) funded by the German Cancer Aid was initiated. Initial recommendations are built on evidence-based literature. Consensus was defined in advance with ≥80% agreement based on the question of whether each recommendation was unambiguously formulated, relevant, and realizable for a CCC.
A total of 38 experts (73.1%) from 15 CCCs performed all three Delphi rounds. Consensus was achieved for 29 of 30 recommendations. High agreement related to having an organizationally and spatially independent palliative care unit (≥6 beds), a mobile multiprofessional SPC team, and cooperation with community-based SPC. Until round 3, an ongoing discussion was registered on hospice volunteers, a chair of palliative care, education in SPC among staff in emergency departments, and integration of SPC in decision-making processes such as tumor boards or consultation hours. Integration of SPC in decision-making processes was not consented by a low-rated feasibility (76.3%) due to staff shortage.
Recommendations should be considered when developing standards for cancer center of excellence in Germany. Definition and implementation of indicators of integration of SPC in CCCs and evaluation of its effectiveness are current and future challenges.
General and specialized palliative care (SPC) is an integral part of comprehensive cancer care. However, significant diversity concerning the design of SPC in the German Comprehensive Cancer Center (CCC) Network led to the establishment of consensual best practice recommendations for integration of SPC into the clinical structures, processes, research, and education throughout the CCC network. The recommendations contribute to a greater awareness relating to the strategic direction and development of SPC in CCCs. The access to information about SPC and access to offers regarding SPC shall be facilitated by implementing the recommendations in the course of treatment of patients with cancer.

BACKGROUND: Recently, the concept of integrating oncology and palliative care has gained wide professional and scientific support; however, a global consensus on what constitutes integration is unavailable. We conducted a Delphi Survey to develop a consensus list of indicators on integration of specialty palliative care and oncology programs for advanced cancer patients in hospitals with ≥100 beds.
METHODS: International experts on integration rated a list of indicators on integration over three iterative rounds under five categories: clinical structure, processes, outcomes, education, and research. Consensus was defined a priori by an agreement of ≥70%. Major criteria (i.e. most relevant and important indicators) were subsequently identified.
RESULTS: Among 47 experts surveyed, 46 (98%), 45 (96%), and 45 (96%) responded over the three rounds. Nineteen (40%) were female, 24 (51%) were from North America, and 14 (30%) were from Europe. Sixteen (34%), 7 (15%), and 25 (53%) practiced palliative care, oncology, and both specialties, respectively. After three rounds of deliberation, the panelists reached consensus on 13 major and 30 minor indicators. Major indicators included two related to structure (consensus 95%-98%), four on processes (88%-98%), three on outcomes (88%-91%), and four on education (93%-100%). The major indicators were considered to be clearly stated (9.8/10), objective (9.4/10), amenable to accurate coding (9.5/10), and applicable to their own countries (9.4/10).
CONCLUSIONS: Our international experts reached broad consensus on a list of indicators of integration, which may be used to identify centers with a high level of integration, and facilitate benchmarking, quality improvement, and research.