Colorado Health Foundation

Physicians often hold leadership roles in implementing interdisciplinary rounds (IDR) in clinical settings, thus understanding physician perspectives of bedside IDR is crucial. To understand physicians' perspectives of structured bedside IDR. Qualitative descriptive study. Medical and transitional year resident and hospitalist physicians participating in structured bedside IDR in a community teaching hospital affiliated with a large academic center. We conducted semi-structured interviews and focus groups with study participants about their experiences with participating in structured bedside IDR between July 2017 and April 2018. All interviews were recorded and professionally transcribed. We used thematic analysis to identify key themes. We interviewed 41 resident physicians and 10 hospitalist physicians and discovered five key themes that highlight physician impressions of bedside IDR. Bedside IDR decreased unnecessary care, screened for risks/errors, created a shared mental model of care, and increased physician empathy for the patient and the interprofessional care team. Physicians felt patients valued the streamlined communication they experienced but questioned the intrusiveness of large healthcare teams. Challenges to bedside IDR included the meaningful engagement of key stakeholders and, particularly for resident physicians, the difficultly of managing unstandardized communication in a standardized time-sensitive setting. Structured bedside IDR have the capacity to improve patient care, interprofessional teamwork, and physician empathy for patients and the interprofessional team. However, sustained leadership support and clearly defined rounds goals and objectives are necessary ingredients to maximize the benefits and address the challenges of bedside IDR.

Ocular emergencies are a frequent occurrence in the emergency setting. Fortunately, point-of-care ultrasound (POCUS) lends itself exceptionally well to ocular evaluation. Here, we present a unique case of central retinal artery occlusion rapidly diagnosed with POCUS in a patient with a recent COVID-19 diagnosis.

The 2011 publication of John Kania and Mark Kramer’s influential paper, "Collective Impact," caught the attention of organizations across sectors, including nonprofit organizations and philanthropies. The Colorado Health Foundation was one of the organizations that saw the potential of collective impact to help tackle the state's complex, systems-level health issues. This article describes a collective impact initiative and the role that developmental evaluation – and a realist framework – played in aiding both the initiative’s steering committee and the Colorado Health Foundation in making decisions about the initiative's accomplishments and future. The article highlights the developmental evaluation approach, how that informed decisions, and how it helped surface broader insights about the many challenges of doing highly collaborative work.

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Increasing blood flow (hyperaemia) to exercising muscle helps match oxygen delivery and metabolic demand. During exercise in hypoxia, there is a compensatory increase in muscle hyperaemia that maintains oxygen delivery and tissue oxygen consumption. Nitric oxide (NO) and prostaglandins (PGs) contribute to around half of the augmented hyperaemia during hypoxic exercise, although the contributors to the remaining response are unknown. In the present study, inhibiting NO, PGs, Na+ /K+ -ATPase and inwardly rectifying potassium (KIR ) channels did not blunt augmented hyperaemia during hypoxic exercise beyond previous observations with NO/PG block alone. Furthermore, although inhibition of only Na+ /K+ -ATPase and KIR channels abolished hyperaemia during hypoxia at rest, it had no effect on augmented hyperaemia during hypoxic exercise. This is the first study in humans to demonstrate that Na+ /K+ -ATPase and KIR channel activation is required for augmented muscle hyperaemia during hypoxia at rest but not during hypoxic exercise, thus providing new insight into vascular control. Exercise hyperaemia in hypoxia is augmented relative to the same exercise intensity in normoxia. During moderate-intensity handgrip exercise, endothelium-derived nitric oxide (NO) and vasodilating prostaglandins (PGs) contribute to ∼50% of the augmented forearm blood flow (FBF) response to hypoxic exercise (HypEx), although the mechanism(s) underlying the remaining response are unclear. We hypothesized that combined inhibition of NO, PGs, Na+ /K+ -ATPase and inwardly rectifying potassium (KIR ) channels would abolish the augmented hyperaemic response in HypEx. In healthy young adults, FBF responses were measured (Doppler ultrasound) and forearm vascular conductance was calculated during 5min of rhythmic handgrip exercise at 20% maximum voluntary contraction under regional sympathoadrenal inhibition in normoxia and isocapnic HypEx (O2 saturation ∼80%). Compared to control, combined inhibition of NO, PGs, Na+ /K+ -ATPase and KIR channels (l-NMMA+ketorolac+ouabain+BaCl2; Protocol 1; n=10) blunted the compensatory increase in FBF during HypEx by ∼50% (29±6mLmin-1 vs. 62±8mLmin-1 , respectively, P<0.05). By contrast, ouabain+BaCl2 alone (Protocol 2; n=10) did not affect this augmented hyperaemic response (50±11mLmin-1 vs. 60±13mLmin-1 , respectively, P>0.05). However, the blocked condition in both protocols abolished the hyperaemic response to hypoxia at rest (P<0.05). We conclude that activation of Na+ /K+ -ATPase and KIR channels is involved in the hyperaemic response to hypoxia at rest, although it does not contribute to the augmented exercise hyperaemia during hypoxia in humans.

Many foundations are seeking to impact root causes of social issues through funding initiatives that are both technically and socially complicated and where past experience is no guarantee of success. These situations exhibit the growing need for more adaptive funding approaches, such as emergent philanthropy. This article looks at an application of emergent strategy at the Colorado Health Foundation. It shares tools used to design the funding approach for the foundation’s Creating Healthy Schools initiative, including support for grantees in refining their grant-proposal budgets and activities, decreasing duplication, and leveraging resources more effectively. This article will look at lessons learned, including the need to continue to evolve emergent philanthropy and collaboration not only between funders and grantees, but between funders themselves. The authors hope the tools experimented with in this case will help other foundations design and implement system-change strategies in complex environments.

To compare the degree of agreement of sonographic optic nerve sheath diameter (ONSD) measurements by ultrasound fellowship-trained and resident emergency medicine (EM) physicians. Ten ultrasound fellowship-trained EM attending physicians from multiple institutions and 51 resident EM physicians at a single residency were enrolled to measure the ONSD using a computerized ruler on five separate still-frame sonograms of adult eyes that included the retrobulbar optic nerve. Descriptive and bivariate statistics for each ultrasound image were calculated to compare median ONSD measurements among groups. Intraclass correlation coefficients (ICCs) were calculated to estimate the inter-rater reliability. Although the median ONSD measurement of each image did not significantly differ between resident and ultrasound fellowship-trained EM physicians, we found greater variation in agreement of ONSD measurements by resident EM physicians (ICC 0.50; 95% confidence interval 0.25-0.89) than ultrasound fellowship-trained EM physicians (ICC 0.73; 95% confidence interval 0.44-0.96). Although both resident and ultrasound fellowship-trained EM physicians showed good inter-rater reliability of ONSD measurements, variation in agreement among ultrasound fellowship-trained EM physicians may be as wide as 0.44, suggesting that even in skilled hands, ultrasound measurement of the ONSD may not be as dependable a screening tool for elevated intracranial pressure as previously suggested in the literature.

Strategic learning, a critical if relatively new lens for philanthropy, is neither simple nor efficient to institutionalize or practice yet — foundations are still figuring out how to do it well. In 2015, the Episcopal Health Foundation launched a project to distill lessons about how leading foundations configure evaluation and learning, and how they allocate related responsibilities in support of strategic learning. This article addresses different models that foundations use to establish and staff evaluation and learning functions, what other organizational considerations they should take into account in order to prioritize strategic-learning work, and what tools and approaches can be used to initiate strategic learning. Interviews with officers from more than a dozen foundations revealed that strategic learning does not require wholesale structural and cultural change; an incremental approach, instead, can phase in greater complexity as foundations expand staff capacity. The interviews also uncovered several areas where further exploration of system building and practice at foundations has potential for advancing the field.