The purpose of the program was to provide health care providers with the knowledge and skills required to comfortably identify and assist women experiencing IPV in the fracture clinic. The program consisted of an introductory video, interactive online modules, and an in-person presentation by a local IPV champion. The study aim was to qualitatively evaluate the feasibility, acceptability, and perceived value of the program. We conducted semi-structured interviews with 10 champions and 23 participants and identified themes using a qualitative descriptive approach. Champions and participants expressed a strong satisfaction with the program. Champions also described several barriers and facilitators to program implementation. Additionally, we identified themes through analysis of interview data from champions  and participants . The program showed promising results, as both champions and program participants had overall positive experiences completing the program. Their suggestions for improvement have been used to refine the program, which is now publically available for educational purposes through  Intimate partner violence (IPV), sometimes referred to as domestic violence, is defined as harm inflicted by one’s past or current partner and may consist of physical, sexual, economic or psychological abuse  as the second most common physical manifestation of IPV  specifically for orthopaedic surgeons, surgical trainees, and other HCPs who care for patients in a fracture clinic setting  were asked to become local EDUCATE champions. Local IPV champions received in-depth training about the EDUCATE program from a social worker (DT). The champion training was delivered through a 1.5 h in-person session held at a large annual meeting of a prominent orthopaedic association. Prior to the training, champions reviewed all components of the EDUCATE program . During the training session, the social worker reviewed the in-person training presentation with champions and elaborated on key concepts and teaching points. The champions were then provided with an opportunity to ask questions. The meeting was attended by seven of the eleven champions from four of the seven participating fracture clinics. The remaining four champions from three of the participating fracture clinics received the same training via teleconference. Local IPV champions were responsible for becoming program curriculum experts to implement the program at their local fracture clinics and were encouraged to tailor the training content to maximize applicability.The EDUCATE program was implemented at seven North American fracture clinics, six in Canada and one in the United States beginning in November 2016. All EDUCATE champions received the champion training prior to implementing the program. All local orthopaedic surgeons, surgical trainees, and other HCPs who treat patients at participating fracture clinics were then invited by their local champions to participate in the EDUCATE program. The number of potential participants across each site varied from 12 to 86 . Training and implementation at each site were completed by June 2017.The project manager from the McMaster University Methods Centre (TS), invited all champions, via email, to participate in a qualitative interview about their experiences implementing and delivering the EDUCATE program at their respective fracture clinics. At least one champion from each site consented to participate in an interview. All champion interviews were conducted by TS, lasted approximately 20 min, and were completed between 1 and 105 days after program implementation. Champions were professionally acquainted with the interviewer and had a professional relationship with the Principal Investigator at the time of the study. Additionally, local research personnel from each fracture clinic identified a subset of program participants via purposeful and maximum variation sampling to participate in a qualitative interview about their experiences receiving the program. Purposeful sampling aims to identify information rich cases (i.e. participants who are likely to provide in-depth information about the phenomenon of interest) Patton . MaximumDuring semi-structured interviews, champions and participants were asked about their experiences with program implementation and participation and shared their perspectives on the feasibility, acceptability, and perceived value of the program. The interviewer used reflection, paraphrasing, clarifying and summarizing techniques in all interviews to provide interviewees with the opportunity to clarify and add new ideas to the discussion. Interviews were conducted over the phone or in-person with an interview guide comprised of semi-structured questions to inform the discussion and allow for exploration of new topics. No one else besides the interviewer and participant was present for the interviews. All interviews were audio recorded with participants’ consent and transcribed verbatim. Interview invitations continued to be sent until data saturation was achieved. We considered the data to be saturated when no new themes emerged, and we ad obtained interview data from at least one participant at each of the participating sites (excluding the site in which no participants agreed to participate in an interview).Data collection was a reflexive and interactive process where data collection and analysis occurred simultaneously to allow new themes identified in early interviews to be explored in subsequent interviews, and to monitor for data saturation. All interview transcripts were coded by two of three independent reviewers and analysed using a conventional qualitative content analysis (Hsieh and Shannon This study was approved by the Research Ethics Board at McMaster University (REB# 1816) as well as the Research Ethics Boards or Institutional Review Boards of each participating site and was conducted in accordance with humane and ethical research principles.Ten champions and 23 program participants consented to participate in the qualitative interview process. Aside from one site in which no participants consented to an interview, the minimum number of participants from each site was 1 and the maximum was 9 with a mean of 3. EDUCATE champions were predominantly orthopaedic surgeons, however participants also included non-physician HCPs, and orthopaedic surgery residents (see Table Both champions and EDUCATE program participants reported high satisfaction with the IPV education program. This included champions, “I think that everyone took away something [from the program’]”, more experienced providers, “it’s a necessary, valuable program”, and more novice providers, “I thought it was a really helpful program, especially being in my first year of residency, I felt it was nice to kind of have that validational baseline knowledge”. Participants discussed plans to incorporate the training they received from the program into their practice through increased IPV screening. One participant stated, “I’ll be more likely to ask certain questions with my awareness being raised”. Another participant expressed, “I think that [IPV is] something that I’ll look for in future residency and during practice as well”. One participant also shared an example of a change in screening practice due to the EDUCATE program, “There was a patient that I saw a couple weeks back where I did screen for IPV, and I would not have before the training...”. Similarly, one champion shared that, “I’ve already had people come up to me and say, this person said x, y, and, z you know, where are those [IPV] information sheets.” The experiences of both champions and participants, though unique, both demonstrated that the program was perceived to be valuable.When asked about the implementation of the EDUCATE program, champions identified a series of barriers and facilitators.Champions described time constraints, ensuring completion of the online training modules, and redundancy in content, as barriers to program implementation. Champions discussed difficulty identifying time to schedule training, both in their own schedules and with the schedules of participants. Champions suggested that for the program to be sustainable, it would need to fit into existing educational times such as webinars or symposiums through professional orthopaedic associations, or use of site-specific training videos or online modules, and incorporation into residency curricula. For instance, one champion expressed it was easier when “we just made this part of our educational curriculum”. Champions also expressed difficulty in ensuring completion of the online training modules since the modules had no built-in way of tracking who had completed the training. Champions from two sites chose to require completion of the online modules by providing them in a group setting; however, this increased the time commitment. Lastly it was stated that some of the content from the online modules was repeated in the in-person presentation, increasing redundancy. This redundancy, although identified as a barrier, was viewed as a potential benefit by some champions to underscore key points.Delivering training during protected academic or professional development time, obtaining buy-in from key personnel, and inclusive training were identified as facilitators to program implementation. As finding time for EDUCATE training was identified as a barrier, it is not surprising that champions identified using protected academic or professional development time to deliver the program as a potential facilitator. Doing so made the EDUCATE program more feasible for participants as “the expectation is that as many providers as possible attend academic day”. In addition, obtaining buy-in from key administrators was a crucial step in securing protected academic or professional development time for training and it encouraged others to view the training as important which, in turn, encouraged attendance. Similarly, champions reported having inclusive training as a facilitator. Champions described an added value in having as many people from the fracture clinic as possible participate in the training. This allowed participants to learn from others with more experience and become comfortable integrating the knowledge gained training into their practice because “everybody was at the teaching session and knows that this is something that we should be doing”.…the only thing was that I thought I did it too far in advance of when we actually trained staff here, because I found myself going back through the presentation and trying to remember what I was actually supposed to teach them.Most champions reported feeling comfortable in delivering the program, “I felt quite comfortable with it, with the preparation that I had from [the champion training]” but stressed the importance of customizing the program to include their local resources “…we really liked having a bit of freedom with the presentation at the end because you could really tailor it to…our local resources and what was expected of [the residents] at the clinical site that they worked at”. Champions also discussed the benefit of adapting the program to include cases from their own practice rather than generic case studies. Many preferred this approach because they could present the case in greater detail, show corresponding x-rays, and share patient outcomes. Lastly, champions often commented on the perceived receptiveness of program participants to the training. Champions indicated that overall, they thought that participants appreciated receiving the EDUCATE program, particularly the in-person training component, and found it to be a valuable experience. Champions reported that participants were engaged and receptive throughout the program and,If they had any questions they weren’t shy to ask them, and from the questions they were asking me, it seemed like they were taking information, processing it, and then thinking…beyond what does that mean for me and what would that actually look like in clinic.Following a discussion on implementation of the program, champions were asked about their experiences delivering the EDUCATE program. Three themes were identified; champion training, program delivery, and perceptions about program participants’ receptiveness to training. Champions expressed satisfaction with the champion training they received prior to implementing the program at their respective fracture clinics “I thought it was very helpful, [the champion trainer] did a nice job, in giving examples, explaining things further, and really emphasizing key points. So, I thought that was extremely helpful”. Champions expressed that it helped them to become familiar with the program content which allowed them to overcome challenges that arose in training. Champions who received training via teleconference expressed similar satisfaction with the training and did not share differing experiences from champions who attended the in-person champion training session. There were several comments however stating that there may have been too long of a gap between the champion training and implementation at the fracture clinic,As a health care worker…we get very minimal training in this area unless you’re actively involved with women’s health, or you know working in an assault violence workplace, we get I would say no training for this. So, for all of us I think it was very good to go attend the women’s EDUCATE seminar…This interest in the program was also observed by champions, “I felt that I had a very engaged audience, they were very interested”. Participants discussed appreciation of the in-person component, along with other aspects of the program content and delivery, with one participant explaining,…I think it helps to be in person, particularly with a topic like this because I actually asked our [champion] how he talks to patients about this, and has he identified patients, and what’s his experience with this?...It’s not just, understanding the background and the statistics and all that kind of the thing, but actually how do you approach this sensitive topic in a real way…The appreciation of the in-person training session was also observed by champions with one champion noting, “I think that people appreciated somebody actually taking the time to go through the strategies for an issue that I know all the staff think is important…”. While attributing value to the in-person training component, a few participants expressed that there was some repetition between the online modules and the in-person presentation; however, similar to the champion reports, views differed as to whether this repetition was beneficial. Additionally, though participants reported sufficient detail and length of the program, they would have appreciated more practical guidance on how learning can be incorporated into clinical practice “if [the champions] could provide… a video of them role playing or [could] list some of the phrases they commonly use and what they found that works well in their practice”. Based on participant feedback the EDUCATE program, although containing information on local resources, could have included additional information on practical applications and further education in IPV. For instance, participants expressed some remaining uncertainty about where to locate IPV resources within their fracture clinics “…if there was anything to stress it was ‘okay, exactly where are these resources’ because at some point it wasn’t exactly clear where in the clinic I’d find them”. Participants also expressed wanting to know more about reporting requirements for IPV when children are involved, specific phrases to use when asking about IPV, residents’ roles in the process of initiating IPV assistance, and victim follow-up obligations. Participants suggested several program enhancements to address some of these uncertainties. These suggested enhancements included videos of IPV champions demonstrating how to ask and assist with IPV in the fracture clinic setting, more discussion of local IPV cases, opportunities for small group discussions during training, monthly meetings to practice and update skills, and additional information on legislative IPV reporting requirements.Three themes were identified from participant interviews that related to the acceptability of the program including value of the training experience, useful program content, desire for more education, and suggested program enhancements. Participants in the EDUCATE program expressed the value in an increased awareness of IPV, a need for the EDUCATE program and an appreciation of the in-person component of the training. One participant explained that,Our study qualitatively evaluated the experiences of local champions and program participants throughout the implementation and delivery of an IPV educational program specifically for fracture clinics. The results of this study have been used to improve the EDUCATE program, and a revised version of the program is now available to fracture clinics across Canada. We found that overall, program implementation was a positive experience for both local champions and participants, and that the program was perceived as valuable, acceptable, and feasible. Participants felt the program increased their awareness of IPV and that the training was relevant to their practice. This is inline with the results from the quantitative evaluation of the EDUCATE program which found that participants’ IPV-related knowledge, attitudes, beliefs, and behaviours, as measured by the Physician Readiness to Manage IPV questionnaire (Short et al. Overall, EDUCATE program champions felt implementing and delivering the program in their fracture clinics was feasible, and expressed positive experiences. To the best of our knowledge, no previous studies have looked at the experiences of individuals who deliver IPV educational programs within health care settings. However, other studies have employed a “train-the-trainer” approach with positive results (Bonds et al. Overall, EDUCATE program participants believed that the training they received was valuable, that the program was acceptable. This viewpoint was also echoed by champions. Participants also expressed a desire for additional education and suggested enhancements to the program. This finding is in line with the results of a previous scoping review of the literature on IPV educational programs which found that multiple studies reported positive program evaluation results (Sprague et al. Finally, participants expressed plans to incorporate training into their practice, with some participants already reporting changes. This accords with previous research which has found that IPV education can impact HCPs awareness of their role in IPV identification and assistance within their practice (Protheroe et al. Due to the design, this study has limitations. Firstly, recruiting volunteers to participate likely led to the inclusion of a disproportionate number of individuals in our study who are interested in the topic of IPV and IPV education. However, since the goal of purposeful sampling is to identify and include individuals likely to provide in-depth information about their experiences participating in the educational program, this selection aligns with our study objective. It is also possible that participants who valued the program were more likely to agree to participate in an interview than participants who did not value the program; therefore, interview data we obtained may not be representative of all possible participants. Secondly, our study is limited by a small sample size in terms of participating institutions, champions, and program participants. However, small sample sizes are common in qualitative research and generalizability of findings to other populations is typically not the aim, rather the intent is for the reader to determine the transferability of results to their clinical environment Leung . ThirdlyA qualitative evaluation of the implementation of the EDUCATE program found that both champions and program participants had overall positive experiences completing the program. Champions and participants suggested several strategies to improve the program that were used to refine it prior to widespread implementation.


The second victim phenomenon occurs when health-care providers experience significant professional distress  and psychological distress  as a result of medical errors or adverse patient outcomes. Few hospitals have institution-wide systems in place to assist employees through the recovery process.At Nationwide Children’s Hospital (NCH), a peer-based support program called “YOU Matter” was executed and spread hospital-wide. The program emulated the framework and execution strategy designed by University of Missouri Health Care’s (MUHC) “forYOU” Team. Strategic elements of the program’s structure were reviewed and adapted for NCH with system-wide deployment and enhancement to include electronic peer support reporting. This article summarizes program implementation, management, and sustainment over the past 2 years.By following University of Missouri Health Care’s model, we successfully deployed an institution-wide second victim program. Since the November 2013 initiation, we have documented 232 peer and 21 group encounters. High-risk clinical areas for second victimization at NCH included the emergency department (ED), pediatric intensive care unit (PICU), cardiothoracic intensive care unit (CTICU), and pharmacy department. Registered nurses (RNs) and licensed practical nurses (LPNs) have had the highest number of encounters necessitating second victim support (32%). Supported staff reported improved emotional state and improved return-to-work metrics.An organization’s culture of patient safety can be enhanced by ensuring staff psychological safety. Programs like “YOU Matter” and the “forYOU” Team are essential building blocks to improve the overall safety culture and quality of care. Implementation of “YOU Matter” at NCH validates the MUHC program and demonstrates its generalizability to other health-care institutions. To Err is Human: Building a Safer Health System,1 a paradigm shift in medical error reporting has occurred.5 There is some indication that patient safety has improved.6 However, the support systems for health-care workers involved in medical errors are lacking.9 These second victims of unanticipated clinical events suffer emotionally and are traumatized by the events.16 Researchers estimate that 10–40% of health-care professionals have been second victims.16 Affected individuals may suffer from guilt, depression, sleep disturbance, anxiety, or even suicidal ideation.19 Although the vast majority of hospitals rely on employee assistance programs or pastoral care for providing “just-in-time” clinician support after adverse events, these services are often underutilized, and the suffering provider carries the burden of the adverse outcome.11Since the publication of the Institute of Medicine’s 20At Nationwide Children’s Hospital (NCH), the need for a comprehensive system-wide support system for second victims became apparent when unit leaders asked for the development of a second victim program. These leaders had learned about a system-wide support network at University of Missouri Health Care (MUHC) called the forYOU Team. The forYOU Team harnesses existing resources within health-care systems to address unmet needs of clinicians suffering as second victims.12 The NCH pharmacy leaders replicated the survey and found similar findings among their staff. With a response rate of 67% (121/181), results revealed that 28% (34/121) of respondents suffered anxiety and sleep disturbance following an adverse event, 10% (12/121) contemplated leaving the institution, and 3% (4/121) considered leaving the pharmacy profession.13 As the NCH survey mirrored that of MUHC, the NCH staff decided to collaborate with MUHC patient safety researchers to initiate a similar second victim support program starting in 2012. This article describes the collaboration with MUHC researchers and the replication of the forYOU program.In an MUHC study, 30% (268/898) of responding health-care professionals reported second victim symptoms as a result of a patient safety event. Approximately 15% (40/269) reported seriously contemplating leaving their profession.6 It is one of the founding members of the Solutions for Patient Safety and was the first pediatric institution to post its serious safety event online (see http://www.nationwidechildrens.org/serious-safety-event-rate-sser).NCH is a free-standing pediatric, academic institution with over 10,000 employees, approximately 1,200 medical staff, approximately 17,000 inpatient admissions and more than 1 million patient contacts per year. NCH has a robust voluntary adverse event reporting system and a strong culture of patient safety.In July 2013, we reached out to MUHC researchers to discuss strategies for development of a hospital-wide second victim support structure. Six components of team design identified were (1) identify a core steering team, (2) identify an executive sponsor, (3) develop unit-based teams, (4) develop team branding/marketing, (5) educate and train peer supporters, and (6) track data to ensure effectiveness  agreed to serve as executive sponsor of the YOU Matter program. Director of Quality Improvement Services (A.R.) acted as a supportive resource throughout implementation. The executive sponsor and director of Quality Improvement Services served as liaisons to other executives, provided guidance and leadership, and exercised administrative oversight. The second victim’s mission aligned perfectly with one of the hospital’s strategic quality initiatives, Treat Me With Respect.23 Consequently, the YOU Matter program received financial support that was instrumental in the success of the program.Program development began by obtaining the support and involvement of key NCH leaders, including hospital executives, members of quality improvement/safety teams, and the legal department.13 This successful pilot study supported the hospital-wide expansion of the NCH second victim program, first to the emergency department and subsequently to the perioperative department, intensive care unit’s (ICU), and surgical units in March 2014. The program was spread throughout all inpatient units as well as urgent cares, outpatient primary care clinics, and ambulatory specialty clinics. Timeline for program implementation is outlined in Figure In November 2013, an initial demonstration pilot study among NCH pharmacy staff was conducted by Krzan et al.We developed marketing materials  Digital quality boards visible in staff lounges and conference rooms described the second victim phenomenon and promoted the new program. These various methods of marketing the program increased staff awareness and desire to become involved.Outreach occurred initially with unit leaders then expanded to all employees. Inpatient clinical leaders were educated on the second victim phenomenon and were asked to nominate individuals who could serve as unit program champions. Desired characteristics of the unit champions included strong leadership skills, trustworthiness, effective communication skills, and personal second victim experience. Once confirmed, the leads committed to training and to oversee other peer supporters within their unit/department.24 an overview of existing literature, necessary skills for responding to second victims, provision of referrals and escalation of care, and legal/confidentiality considerations .Members of the multidisciplinary steering committee provided tier 1 education to the entire institution through presentations regarding ways to identify a second victim, providing essential support, and referral processes when higher levels of support are warranted. Tier 2 support consisted of trained peer supporters. The goal for each unit was to have 10% of staff trained as peer supporters with all shifts and disciplines represented. This degree of participation allowed for 24/7 availability of YOU Matter team members.Peer supporters received identification badge extenders for easy recognition as a peer supporter.Tier 3 support included a team of chaplains, social workers, and clinical psychologists. A clinical psychologist provided training on responding to second victims and served as a team mentor. Tier 3 support also incorporated existing Employee Assistance Program (EAP) resources.The YOU Matter program’s interventional model of support mirrors MUHC’s structure. Peer supporters provide first-line support to second victims and report to assigned leaders within various clinical areas. The leaders are capable of escalating issues to the core steering committee and tier 3 resources as needed.As with its MUHC counterpart, staff may activate the YOU Matter program support through the following 4 mechanisms Fig. :Direct contact with peer supporters as identified by the YOU Matter badgeUtilization of the YOU Matter 24/7 hotlineUsage of the Second Victim Support e-mail groupDirect contact with core team members as identified on intranet site.13 The primary purpose of documentation is to quantify frequency and types of second victim encounters.As the second victim program continued to grow, the need for efficient communication and documentation became apparent. A “Second Victim SharePoint site” was created serving as a central, electronic portal, to manage the program, share information, and document encounters .We established security permissions to ensure confidentiality of the second victim program and to limit access to the YOU Matter Program SharePoint site. Access was granted at various security levels depending on the individual’s role. Once staff completed initial training, the permission level was changed to “peer supporter” so they could document peer/group encounters. Individuals were able to access only peer and group encounter forms that they initiated. The program director had access to all encounters and tracked necessity for further interventions.13 Data collected from the electronic portal were analyzed to better understand the second victim experience on NCH staff and to implement system changes to enhance support.Electronic peer/group encounter forms were adopted from MUHC with nonidentifiable personal health information data captured and converted to the online platform .The second victim SharePoint site provides real-time dashboard metrics with the following information: number of peer supporters, disciplines of peer supporters, the number of peer/group encounters, and encounter locations.Since the November 2013 team deployment, there are over 300 peer supporters trained, 232 peer and 21 documented group encounters, and 30 leaders identified. Demographically, nurses comprise 44% of peer supporters, and other staff  include 30% of peer supporters Fig. . AdditioNurses have the highest number of encounters documented  as receiving second victim support, followed by other staff (34), which included certified nurse anesthetists, interpreters, suture technicians, child life specialists, physical/occupational therapists, and medical assistants. Patient care assistants were involved in 33 encounters followed by, physicians (19), social workers (19), and pharmacists 18; Fig. .Since program conception, 6 common reasons for peer encounters have been patient death, emotional stress, trauma, cardiac arrest, medication error, and alleged child abuse cases Fig. . The mosThis article describes replication of MUHC’s forYOU Team at a large pediatric institution. Key elements to the success of this project were the establishment of an effective working relationship between 2 independent health-care entities and the willingness to “test” key team infrastructure components within the context of a unique health-care entity. This successful partnership permitted NCH to implement a successful second victim support program. Using MUHC’s established model for clinician support, NCH deployed an operational program in 6 short months. The primary infrastructure components replicated included team design, the Scott Three-Tiered Model of Second Victim Support, training materials, and program monitoring tools. Through the fruitful efforts of the YOU Matter team, organizational recognition of clinicians in distress and the social support of second victims has steadily increased. Implementation of the team has enhanced the overall culture of sensitivity and psychological safety at NCH.We have replicated critical aspects of the MUHC second victim support program. Using the MUHC framework for the design of a support team and implementation strategies were considered essential to a timely program launch. Second, hospital administration support was necessary for identification of an executive sponsor being strategic. Without the support from hospital administration and guidance from the legal department, a peer support program would be difficult to operationalize successfully. Third, the creation of a multidisciplinary core team was critical. Peer-to-peer education was more readily received. Recruitment was also more successful on a peer-to-peer basis. Peer recommendations were the foundation of the program. The core team represented all hospital staff from inception to be appropriately impactful. Fourth, program promotion involved the institution’s marketing department in helping brand the team concept and increase awareness at every level of the institution.Lastly, documentation of events was essential to track program impact and identify targeted areas in need of additional support. Constructing an electronic tracking system via SharePoint allowed team leadership to collect valuable data regarding the incidence of second victims, types of encounters, types of emotional support provided, and disciplines that were involved.The justification for a second victim program is often not concrete and lacks obvious financial incentives for hospital systems. Delays may occur due to these constraints when implementing a program. Investing time in education and raising awareness of the second victim phenomenon among hospital administration is helpful to augment program initiation.The YOU Matter program had a disproportionate representation of peer supporters across disciplines. The data show that approximately 6% of employees at NCH received training as peer supporters . Nurses may be overrepresented because of their workday availability and involvement in hospital committees. For future team development, we endorse strategic recruitment efforts that yield representative distribution representing all staff. The Nationwide Children’s goal was to incorporate at least 5–10% of staff trained as peer supporters for each area/unit. Having a variety of individuals trained as peer supporters on various shifts allows for more opportunities to access a peer supporter if needed.26Interestingly, as we disseminated the program throughout the institution, and staff awareness increased regarding the second victim phenomenon, the team received anecdotal reports from nonclinical staff who were adversely impacted by traumatic clinical events. Although the definition of second victims primarily involves clinician, we recognized the need to include nonclinical staff as well. As with the MUHC experience, the YOU Matter team expanded the program to include security guards, interpreters, unit clerks, environmental services staff, and other nonclinical employees.The YOU Matter data demonstrate that higher numbers of second victims exist in high-risk areas and units with child abuse and undesirable patient outcomes. The ED and ICUs had the largest number of encounters documented. This trend is not observed in perioperative or surgical areas perhaps due to poorer documentation or fewer trained peer supporters compared with the ED and ICU. Although peer supporters may provide second victim support, documented encounters of the emotional support provided may be lacking.12Future directions for the YOU Matter program include recruiting new members to more accurately reflect staff distribution and to study the effectiveness of the peer support model. Previously, MUHC’s forYOU Team demonstrated that the most efficient kind of support comes from peers.Though survey results from employees appear to find the program beneficial, it will be important to define further the effects of the YOU Matter interventions. We are currently undergoing a study to quantify program effectiveness.When an error occurs, the health-care provider can be overlooked and is left to handle the emotional repercussions alone. A culture of safety for patients is enhanced by a program that it is equally focused on the psychological safety of staff.22 Following the successful MUHC model proved to be an efficient and practical approach to NCH team design and deployment. Health-care facilities without emotional support for staff need to consider the implementation of a second victim peer support program and evaluate its effectiveness.27Peer support is the preferred method of support by medical personnel; however, initiating a large-scale, second victim rapid response team can be a daunting undertaking for any health-care facility.The NCH’s system-wide intervention has demonstrated that second victims occur across the health-care continuum with an increased prevalence in areas of high patient acuity and death. Second victims report improved emotion state and benefit from the program. We feel that rapidly and widely accessible support is critical to an overall culture of safety for any health-care institution. Based on the NCH experience, the MUHC clinician support model is transferrable to other health-care entities with minor modifications and is an efficient way to develop similar future staff support initiatives within health-care facilities.We thank Anamarie Rayburn, Director of Quality Improvement Services; Lois Stepney, LISW, Critical Incident Stress Coordinator and YOU Matter Team Coordinator; Laura Hirschinger, forYOU Team, and Franklin Wall, Administrative Coordinator, YOU Matter Program.The authors have no financial interest to declare in relation to the content of this article.


A national priority at the US Department of Veterans Affairs (VA) is to increase the availability and accessibility of evidence-based psychotherapies (EBPs) across all VA medical facilities. Yet many veterans, particularly those who use remote outpatient VA clinics, still do not receive much needed evidence-based treatment. Strategies are needed for supporting mental health providers at rural VA community-based outpatient clinics (CBOCs) as they translate their clinical training to routine practice. The Coordinated Anxiety Learning Management (CALM) program is a computer-delivered program that supports the delivery of cognitive behavioral therapy (CBT) by providers in outpatient settings to patients with depression and anxiety, including posttraumatic stress disorder.The objectives of our study were to (1) adapt an existing computer-based program to rural VA CBOCs through feedback from key stakeholder focus groups; (2) develop a prototype of the adapted program; and (3) determine the adapted program’s acceptability and feasibility. Mental health stakeholders included VA leaders (n=4) in the implementation of EBPs, VA experts (n=4) in CBT, VA CBOC mental health providers (n=8), and veterans (n=8) diagnosed with a mental health condition treated using the CALM program and receiving treatment in a VA CBOC.An iterative approach comprising 3 waves of focus group discussions was used to develop a modified prototype of CALM. Following each wave of focus group discussions, template analysis was used to rapidly communicate stakeholder recommendations and feedback to the design team. The original program was first adapted through a process of data collection, design modification, and product development. Next, a prototype was developed. Finally, the redesigned program was tested for acceptability and feasibility through a live demonstration.Key stakeholders suggested modifications to the original CALM program that altered its modules’ appearance by incorporating veteran-centric content. These modifications likely have no impact on the integrity of the original CALM program, but have altered its content to reflect better the demographic characteristics and experiences of rural veterans. Feedback from stakeholder groups indicates that changes will help VA patients identify with the program content, potentially enhancing their treatment engagement.The development model was effective for economically gathering actionable recommendations from stakeholders to adapt a computer-based program, and it can result in the development of an acceptable and feasible computer-delivered intervention. Results have implications for developing computer-based programs targeting behavior change more broadly and enhancing engagement in EBP. Ample evidence indicates the effectiveness of evidence-based psychotherapies (EBPs), particularly cognitive behavioral therapy (CBT) ,2, for tDespite this effort, broadly implementing CBT and other EBPs in VA treatment settings has been a challenge ,9, especAn additional challenge at VA CBOCs is ensuring that treatments are delivered with fidelity . Without adequate fidelity, patients are unlikely to experience optimal outcomes from EBPs, even where they are accessible. Although the VA has made great strides in providing EBP-specific training to providers of mental health care, training alone is not sufficient to ensure fidelity ,15. VA COver the last decade, the National Institute of Mental Health-funded Coordinated Anxiety Learning Management (CALM) study  has addrIn this study, we sought to adapt the original CALM program for use in VA outpatient settings, thus, supporting VA CBOC mental health providers in delivering CBT to veterans with anxiety, PTSD, and depression. To achieve this objective, we modified a method common to the field of instructional design and technology (IDT) to guide the redesign of the CALM computer program for use in VA CBOCs. IDT models are prescriptive models that describe a set of activities involved in the planning, implementation, and evaluation of instructional programs . Most IDAs part of this process, 3 waves of focus group discussions were conducted with 4 groups of key stakeholders to redesign and test the CALM program iteratively for use in VA CBOCs. Stakeholder groups included (1) veterans receiving recent mental health care in a VA CBOC and diagnosed with anxiety disorders and depression, (2) CBOC mental health providers, (3) expert CBT VA clinicians, and (4) VA Central Office leaders with expertise in the implementation of EBPs within VA. In this paper, we describe the iterative process used to redesign and test the modified CALM program, as well as modifications used to adapt the program for use at VA CBOCs.We recruited participants from 4 key stakeholder groups: veterans (n=11) with a recent (≥1 visit in the prior 6 months) mental health care visit at a VA CBOC and with a diagnosis of one or more of the following: PD, GAD, SAD, PTSD or depression; CBOC mental health providers (n=11) in the southern region of the United States, including nurses, psychiatrists, social workers, and psychologists; VA expert CBT clinicians (n=6); and VA Central Office leaders (n=5) with expertise in implementing EBPs within VA. We conducted 3 waves of focus group discussions with each stakeholder group.Veteran participants were recruited from one CBOC in Arkansas. Mental health providers were recruited using a general call distributed via email to providers at CBOCs in Arkansas, Louisiana, Texas, and Mississippi. Multiple CBOCs were needed because most CBOCs have only one mental health provider on site. CBT experts were recruited nationally from within the VA, and leaders in implementation of EBPs within VA were recruited from the VA Central Office in Washington, DC CBT experts and leaders in implementation were individually recruited through convenience sampling based on their level of expertise and availability .The purpose of recruiting veteran stakeholders was to help ensure that the modified CALM content was acceptable to the target patient population and reflected veterans’ illness experiences. We included CBOC mental health providers to help ensure that the modified content was acceptable for this group of providers , images and case studies were appropriate for the target patient population, and the navigation and flow of CALM treatment material met the needs of CBOC providers. Inclusion of VA expert CBT clinicians helped ensure that the empirical support underlying the content of the CALM program was not compromised during the modification process. Finally, inclusion of VA Central Office leaders with expertise in EBP implementation within VA helped the study team ensure that CALM was consistent with prior CBT training efforts within VA.Each group of key stakeholders participated in 3 waves of separate focus group discussions. Focus group discussions are a standard method used to garner diverse feedback efficiently on novel and existing products for new product development. CBOC mental health providers, CBT experts, and VA Central Office leaders with expertise in EBP implementation within VA participated in focus group discussions via teleconference with the assistance of Lync, a Web-based meeting portal that allows participants to view the same material simultaneously. In addition to providing feedback via telephone, participants could leave written feedback on the website chat room and email content for the focus group facilitators. Veteran focus groups met in person at a VA CBOC in Hot Springs, Arkansas.All focus group discussions were co-moderated by the principal investigator (MAC) and a co-investigator (THA). Both researchers have extensive experience in qualitative interviewing and facilitating focus group discussions. An interview guide developed for the study was used to ensure that the discussion remained relatively consistent across stakeholder groups and that groups addressed all relevant topics. The same stakeholders were invited to participate in all 3 waves of focus group discussions to maximize the relevance of feedback . Focus group discussions were audiorecorded with permission from participants. The study was approved by the Central Arkansas Veterans Healthcare System Human Research Protections Program.Rapid analytic techniques informed by Sobo et al  and HamiTo analyze focus group discussions, the lead analyst (THA) listened to the audio recording of the first focus group discussion and systematically populated template categories with data. These data consisted of paraphrased content reflecting stakeholder recommendations, observations, reactions, concerns, and questions. The goal was to capture the full range of responses to questions and comments from focus group discussions. After the lead analyst completed summarizing all content from the focus group discussions in the template, she met with the second analyst (MAC) to discuss analytic findings. Discrepancies in how template content was summarized or categorized were resolved through discussion. This analytic process was repeated for each focus group discussion. For focus group discussions held via teleconference, analysts also incorporated written feedback from the website and emails to facilitators into the template. After analyses were finalized for all 4 focus group discussions, findings were compiled and summarized. Analysts each reviewed the summary to ensure the validity of findings. This analytic process was followed for all 3 waves of focus group discussions.A panel of experts reviewed the summary template before it was submitted to the design and development team, including study team members with expertise in CBT, the relevant mental health diagnosis, and software development. The purpose of this panel was to prioritize and determine the feasibility of each recommendation . The summary template was subsequently reduced to actionable recommendations for modification.The CALM computerized program was created to guide and train mental health providers in delivering a course of CBT . CALM waDuring the first wave of focus group discussions, an overview of CALM was presented to each stakeholder group. This also included screenshots from the program, as well as a detailed description of the functioning of CALM for each disorder. Following the overview, stakeholders were given time to ask questions about CALM; then, they were asked to provide initial reactions or recommendations for modifying and adapting the program for use within VA CBOCs.Recommended modifications to the original program were largely “look and feel” changes pertaining to the images and illustrations in the modules. Stakeholders generally reported that the images and illustrations contained in the original program should be more representative of veterans. They recommended reducing the number of images and illustrations depicting college-aged women and men in white-collar occupations  as well as incorporating imagery better reflecting the gender, age, and economic and ethnic or racial diversity of veteran patients. Veteran stakeholders did not like the background color of the CALM program and overall website template; they wanted a new logo developed specifically for the modified VA program.Stakeholders generally also recommended modifying the images in the original program to make it more “culturally congruent” because the original program was not designed to acknowledge veterans’ military service. One expert CBT clinician noted that this can be “very invalidating” for some patients. Stakeholders suggested replacing some existing images with images of people in uniform; however, a veteran stakeholder cautioned that while incorporating images of people in uniform, “We don’t need to see a Vet on every single picture we look at.” Stakeholders also suggested using images of individuals with physical limitations in the Behavioral Activation module to encourage veterans with prosthetics or other physical limitations to engage in physical activities.Furthermore, stakeholders recommended revisions designed to enhance the degree to which veterans could identify with the program content. To achieve this, they suggested incorporating videos into the modules that speak to the unique mental health concerns of veterans. Stakeholders also suggested using existing VA resources, such as the National Center for PTSD’s “About Face” and the VA’s “Make the Connection” websites ,29. ThesFinally, stakeholders were generally concerned that some slides seemed too “content heavy” to be engaging. Several expert CBT clinicians and CBOC mental health providers thought that having to read a large amount of material during an hour-long therapy session might be difficult, and expert CBT clinicians were concerned that younger veterans with traumatic brain injuries would be overwhelmed by busy slides. This concern was validated by feedback from veteran stakeholders, who not only recommended reducing the number of words, but removing excessive images and illustrations. One veteran noted: “Pictures: unless it means something, what’s the point?”A summary of stakeholder recommendations was presented to the expert panel for review, and actionable modifications were identified and prioritized. The study team then collaborated with the software development group to identify images and illustrations better reflecting the gender, age, and economic and ethnic or racial diversity of veterans. They also identified appropriate images of people in military uniform. The images below are examples of CALM module content before  and afteThe team identified already available Web-based resources with videos of veterans describing their mental health concerns, their experiences with a condition and/or seeking mental health care, and ways that treatment helped them  29]. Th. Th29]. Finally, the team followed stakeholder suggestions in identifying links to Web-based resources for veterans and reduced the amount of text on slides identified by stakeholders as too content heavy. These modifications to the original program were submitted to the software development team, which then developed mock-ups, or wireframes, of the initial modifications to show stakeholders in Wave 2.The wireframes were presented during a second wave of focus group discussions with veterans (n=6), CBOC mental health providers (n=10), expert CBT clinicians (n=5), and VA leaders with expertise in the implementation of EBPs within VA (n=5). Wave 2 participants were reminded of the initial version of CALM using graphics and were provided a side-by-side comparison of all modifications. After reviewing the wireframes, stakeholders provided feedback regarding modifications from the first round of focus groups, and a few suggested additional changes to the CALM program.Stakeholders generally agreed that the modified program appeared more “inclusive of veterans that will be using CALM” and “user-friendly” for the veteran population. Although agreeing that the initial modifications were an improvement, one veteran stakeholder requested more images of older males to be more inclusive of Vietnam-era veterans. Stakeholders, particularly veterans, also responded positively to reductions in the amount of text on many slides. One CBOC mental health provider thought that reducing the amount of text would “leave more room for interaction” between providers and veteran patients. Stakeholders also responded positively to the inclusion of videos and links to resources. One younger participant in the veteran focus group who had completed VA treatment for PTSD suggested replacing a video in which veterans described only their treatment experiences with the one in which they explain that treatment is difficult at first, but helps. Finally, one CBOC mental health provider noted that many of his veteran patients were uncomfortable with writing and suggested the program allow veterans the option of verbally describing and recording trauma memories for use in the Exposure module, in addition to writing about them.The expert panel again reviewed a summary of recommendations and prioritized actionable modifications from Wave 2 focus group discussions. Following this, the study team identified images and videos per stakeholder recommendations. The principal investigator (MAC) collaborated with one CALM developer (MAC) to incorporate an option allowing veterans who are uncomfortable with writing to verbally describe and record their traumatic experiences . These mDuring a final wave of focus group discussions, the prototype was pilot-tested by MGC during a live teleconferenced demonstration to 3 stakeholder groups: CBOC mental health providers (n=6), expert CBT clinicians (n=4), and VA leaders in clinic operations and implementation (n=3). Minor problems that arose during the pilot test were recorded in written notes by the study team and rapidly communicated to the design team following the demonstration. Veteran stakeholders (n=4) reviewed modified CALM modules presented in person by the principal investigator (MAC) and looked at an overview of all modifications by the lead qualitative analyst (THA). No remaining concerns about the program were elicited through this final wave of focus groups.In this study, we used an iterative approach to adapt the original CALM program for use within the VA and, particularly, at rural, CBOCs. Overall, key stakeholders suggested modifications to the original CALM program that were largely “look and feel” adaptations that altered the appearance of the modules by incorporating veteran-centric content. This included relatively simple changes, such as replacing images and developing a new template with the VA logo, as well as more significant adaptations, such as embedding videos of veterans describing their treatment and illness experiences and modifying the case studies to better reflect experiences common to rural veterans. These modifications likely have no impact on the integrity of the original CALM program, while altering the content to better reflect the demographic characteristics and experiences of rural veterans.An additional adaptation was to customize the treatment content to allow veterans the option of orally recounting (as opposed to only writing) their trauma experiences. This modification, along with the overall flexibility of the CALM program to meet the treatment needs of veterans with a wide variety of mental health conditions, is consistent with a long-standing cultural shift at the VA toward the provision of patient-centered health care consisting of a menu of treatment options that can be tailored to each individual veteran’s needs and goals for health and well-being ,31. PatiFeedback from stakeholder groups—and, in particular, rural veterans—indicates that these modifications will help VA patients identify with the program content. This could potentially improve patient-provider communication during therapy sessions and increase veteran engagement in EBP for anxiety, depression, and PTSD. Enhancing engagement is important because attrition from EBPs is high among veterans, particularly those with PTSD . In one CALM has the added benefit of being both patient and provider facing; thus, providers—not patients—directly interact with the program. The use of CALM during treatment sessions does not require patients to possess either technological proficiency or access to the internet at home. Future research could explore whether the program helps older patients gain a sense of familiarity with the use of technology in health care, thus, reducing the potential for a deepening digital divide among older adults.Feedback, comments, and suggestions obtained from the 4 stakeholder groups, in tandem with results from similar studies -44, suggThe study design draws upon numerous strengths. An iterative design that included inviting the same stakeholders to participate in 3 waves of focus group discussions helped ensure the relevance and consistency of recommended modifications. The strength of this approach was reinforced by hosting the veteran focus group last, which allowed veterans to respond to the recommendations from the other stakeholder groups. Additionally, collecting feedback from stakeholders who are familiar with rural veterans, EBPs, and clinical practice at VA CBOCs may have increased the acceptability and feasibility of the modified program for use in this population. This approach was aligned with a person-based approach for developing and tailoring technology-based interventions . FinallyOne limitation of our study was that focus group participation declined throughout the study, particularly among veteran stakeholders. Because we were unable to obtain feedback from every stakeholder who participated in the first wave of focus group discussions, it is possible that we may have omitted or failed to implement suggestions as originally envisioned. Additionally, veteran and mental health provider stakeholders were recruited from one geographical region in the southern United States . Thus, stakeholder feedback may not be generalizable to other locations. Although a necessary first step in this direction, this study also does not provide data regarding fidelity to the CBT model or treatment outcomes. A next step in this line of research is to determine whether the modified version of CALM improves VA CBOC mental health providers’ fidelity to the CBT model and improves veteran outcomes. The evidence already indicates that the original CALM program achieves these objectives ,20; thusWe modified the CALM program for use in rural VA clinics based on feedback from 2 waves of focus group discussions with 4 key stakeholder groups. The results of pilot testing the modified program during a third and final wave suggest that the adaptations increased the relevance and acceptability of CALM content for rural veterans and other key VA stakeholders, such as mental health providers at VA CBOCs. It will be important to assess whether using the program as an interface between providers and patients during sessions enhances veterans’ engagement in EBPs. The iterative approach used in this study holds promise for economically gathering actionable recommendations from stakeholders to enhance the acceptability and feasibility of computer-based programs in health care settings.


The diagnosis of sarcoidosis relies on clinical and radiological presentation, evidence of non-caseating granulomas in histopathology and exclusion of alternative causes of granulomatous inflammation. Currently, a proper diagnosis, with a high level of confidence, is considered as key to the appropriate diagnosis and management of the disease. In this sense, this review aims to provide a brief overview on the role of bronchoscopy in the diagnosis of thoracic sarcoidosis, incorporating newer techniques to establish, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), transesophageal ultrasound-guided needle aspiration with the use of an echo bronchoscope (EUS-B-FNA) and transbronchial lung cryobiopsy (TBLC). Most of the literature reports the diagnostic superiority of endosonographic techniques, such as EBUS-TBNA alone or in combination with EUS-FNA, over conventional bronchoscopic modalities in diagnosing Scadding stages I and II of the disease. Moreover, TBLC may be considered a useful and safe diagnostic tool for thoracic sarcoidosis, overcoming some limitations of transbronchial lung biopsy (TBLB), avoiding more invasive modalities and being complementary to endosonographic procedures such as EBUS-TBNA. Sarcoidosis is defined as a multisystem granulomatous disorder of unknown etiology, first described in 1869 by Jonathan Hutchinson . There aWith regards to clinical features, sarcoidosis has variable clinical manifestations and prognosis. Although it can affect any organ, pulmonary and mediastinal lymph node involvement appears in 90% and 85% of cases, respectively . These dSarcoidosis’ diagnosis is based on three basic criteria: (1) clinical and radiological presentation, (2) evidence of non-caseating granulomas in histopathology and (3) no alternative disease associated with granulomas, such as tuberculosis, sarcoid-like reactions in cancers and lymphomas ,5.Clinical manifestations depend on several factors, such as ethnicity, gender, age, location and extension of organ involvement , while rThere are several procedures for obtaining tissue for histological evaluation. Bronchoscopy is frequently performed, as it allows tissue sampling from several anatomic sources potentially affected by the disease, such as airways, lung parenchyma and hilar/mediastinal lymph nodes. The most available are standard bronchoscopic methods, such as endobronchial biopsy (EBB), transbronchial lung biopsy (TBLB) and conventional transbronchial needle aspiration (cTBNA) ,12. BronFlexible bronchoscopy has revolutionized the diagnosis of sarcoidosis, changing from more invasive procedures  to less invasive ones . In this review, BALF was also considered as a standard bronchoscopic technique.EBB is an established minimally invasive outpatient technique, enabling sampling, under direct vision of the proximal airways . It is pThe diagnostic yield of EBB for sarcoidosis ranges from 20% to 61% ,16. It iDespite the combined used of TBLB and EBB, about one-third of all bronchoscopies fail in diagnosing sarcoidosis . FinallyAs reported in the ATS/ERS/WASOG Statement on sarcoidosis, published in 1999, TBLB was considered the first choice for tissue sampling diagnosis . The diaAs limitations of this technique, we highlight those related to the sample obtained, namely (1) quality, since it cannot represent the lung architecture due to the crush effect of TBLB and (2) small size . On the TBLB and EBB have long been the only endoscopic techniques available to diagnose sarcoidosis, until cTBNA enabled bronchoscopists to sample mediastinal lymph nodes with higher diagnostic yields and lower adverse events .Conventional TBNA, first performed with a rigid bronchoscope and then with a flexible bronchoscope, is a well-established technique, but not an image-guided procedure, and, therefore, its diagnostic yield varies widely, ranging from 6% to 90% with better results in stage I of the disease ,19,20,21Combination modalities, such as cTBNA, EBB and TBLB may increase the yield to 70–90%, but it is often associated with longer procedure length and more complications ,41,42. I+ T-lymphocytes [BALF is the simplest and least invasive bronchoscopic procedure and is routinely recommended as an additional procedure to EBB and TBLB in the diagnostic work-up of patients with sarcoidosis . BALF shphocytes .+CD4+/CD4+ ratio below a cutoff point of 0.45 was associated with a better diagnostic performance for sarcoidosis, even in cases with a CD4+/CD8+ ratio < 3.5 [+ T lymphocytes may be a reliable tool in the sarcoidosis diagnostic work-up, regardless of the CD4+/CD8+ ratio. In addition, BALF study also has some importance in the differential diagnosis of sarcoidosis, as it can exclude granulomatous infections, such as fungal or mycobacterial infections [In this context, the differential fluid cells profile may also be useful in distinguishing sarcoidosis from the most common DPLD. Considering that integrin CD103 is expressed by lung lymphocytes, Mota et al. found that patients with sarcoidosis had a significantly reduced CD103 expression in BALF T-lymphocytes, which was more pronounced in the CD4 subset. The BALF CD103io < 3.5 . Thus, tfections .In the past decade, the diagnostic approach of sarcoidosis has been revolutionized by the possibility of sampling intrathoracic lymph nodes under ultrasound guidance (endosonography) through the airways (EBUS-TBNA) or the esophagus (EUS-FNA and EUS-B-FNA) .EBUS-TBNA was introduced in 2002 to stage the mediastinum in lung cancer patients . Over thEBUS-TBNA has revolutionized the sampling method because it is a minimally invasive procedure, performed with a flexible ultrasound bronchoscope with an integrated convex transducer (7.5 MHz) and Doppler mode that offers the operator a direct  visualization of lymph nodes and its characteristics, as well as surrounding structures, allowing the needle tip to be directed to the target area ,23. OnceConvex-probe–EBUS enables access to the upper paratracheal (stations 2R and 2L), lower paratracheal (stations 4R and 4L), subcarinal (station 7), hilar (stations 10R and 10L) and interlobar (stations 11R and 11L) lymph nodes . Its diaTrisolini et al.  performeAccording to Neves et al. , an adeqEUS-FNA is complementary to EBUS-TBNA. In brief, it is a real-time procedure, through the esophagus, providing access to stations 2L, 4L, 7, paraesophageal (station 8) and pulmonary ligament (station 9) lymph nodes . It is nUnlike EBUS-TBNA or cTBNA, additional procedures, such as TBLB or EBB, cannot be performed at the same time as EUS-FNA . EUS-FNAp = 0.139), as was that of EUS-FNA when compared with cTBNA (p = 0.012). In this study, no significant differences were observed between the sensitivity and accuracy of EUS-FNA and EBUS-TBNA.In 2015, Gnass et al.  performeA combined approach of EUS-FNA and EBUS-TBNA, already employed in some centers, could be a potential substitute for other invasive methods to evaluate uncertain mediastinal/hilar masses, as shown by some authors ,29.In 2017, Kocon et al.  publisheIn 2009, Hwangbo et al.  describep = 0.004), and no serious complications were reported. The authors concluded that EBUS-TBNA combined with EUS-B-FNA is an effective and safe approach, superior to EBUS-TBNA alone, in the diagnosis of mediastinal lymphadenopathies [Dhooria et al.  performeopathies .There are few studies on the application of this technique in the diagnosis of sarcoidosis. Oki et al.  used EUS3, international normalized ratio >1.5 or activated partial thromboplastin time >50 s, partial oxygen pressure in arterial blood (PaO2) <55 mmHg, forced expiratory capacity (FVC) <50%, forced expiratory volume in the first second (FEV1) <0.8 L, diffusing capacity for carbon monoxide (DLCO) <35%, diffuse bullous disease, heart disease or a transthoracic echocardiogram estimated pulmonary artery systolic pressure >40 mmHg [Transbronchial lung cryobiopsy (TBLC) is a recent and useful technique for the diagnosis of DPLD ,67,68. T>40 mmHg .TBLC diagnostic yield for undifferentiated interstitial lung disease varies from 74 to 98% when interpreted alone and with a pooled estimate of around 80% ,72,73,74TBLC overcomes the TBLB limitations with regards to quality and sample size, and it avoids more invasive modalities, such as surgical lung biopsy in atypical cases  and can be complementary to endosonography procedures, such as EBUS-TBNA .The advantage of TBLC over TBLB is related to a larger biopsy size with preserved histopathology (avoiding the crush effect of TBLB) , which mIn short, the data suggest that TBLC should be restricted to patients with suspected sarcoidosis and inconclusive TBLB, in whom an alternative diagnosis is likely. However, data on TBLC are still limited, as there are significant variations in technique ,71,72 anOn the whole, although the diagnostic superiority of EBUS-TBNA, as an autonomous modality over conventional bronchoscopic modalities, can be reasonably assumed by comparisons of pooled estimates in the literature, evidence-based data from adequately planned randomized clinical trials are still lacking . Table 2p = 0.004) and EBB , but not better than TBLB . The addition of EBB and TBLB to cTBNA led to improved diagnosis, whereas TBLB (but not EBB) significantly improved EBUS-TBNA yield. Thus, it was stated that EBUS-TBNA alone has the highest diagnostic yield in sarcoidosis, but it should be combined with TBLB for optimal results. With regards to cTBNA (plus EBB and TBLB), the diagnostic yield was similar to that of EBUS-TBNA + TBLB.In 2013, Bartheld et al.  showed aIn 2016, Hu et al.  publishen = 127) or cTBNA (n = 126), and 31 patients from the cTBNA group subsequently performed EBUS-TBNA. The EBUS-TBNA sensitivity was higher, but not significantly higher than that of cTBNA  and 82% (95% CI = 75–90), p > 0.05). The sensitivity of the staged strategy was 94% (95% CI = 89–98). There were no major complications reported. Thus, the authors concluded that EBUS-TBNA was the best diagnostic tool, although not significantly superior to cTBNA. Additionally, the authors also aimed to assess the cost-effectiveness profile of a staged strategy, including cTBNA as the initial test followed by EBUS-TBNA, in the case of inconclusive rapid on-site evaluation (ROSE) results. These findings suggest that, in selected scenarios with high probability of success of the standard procedure, they can be included in a staged strategy with cTBNA as the initial test, followed by EBUS-TBNA, in cases of inconclusive results, without increasing the complications rate and reducing costs [In 2017, Bonifazi et al.  performeng costs . Thus, ang costs , these dng costs .n = 2), prolonged cough) were reported in the total of patients. Bartheld et al. [n = 15) and bleeding (n = 8) after TBLB, and severe cough (n = 1) and minor bleeding (n = 4) after EBUS-TBNA. Also noteworthy are the infectious serious adverse events  of this technique in the subset of sarcoidosis patients [A systematic review and meta-analysis of 15 studies by Agarwal et al.  investigd et al.  published et al. . In addid et al.  in theirpatients ,83. TherIn the available literature, several factors have been stated as affecting the diagnostic accuracy of these techniques: type of lesion, size, location, experience of the endoscopist and cytopathologist, sampling pattern ,85, needp = 0.05; 95% CI = 1.9–42.2) [Tremblay et al.  reported.9–42.2) . TherefoMuthu et al.  performeROSE is a technique that ensures a proper samples’ handling and processing . In 2007In 2015, Trisolini et al.  stated tData concerning the impact of the size and topography of lymph nodes in diagnostic accuracy of this technique are controversial. Some authors have shown that increased lymph node size supports an EBUS-based diagnosis of malignancy. In contrast, others have suggested that lymph node size has little effect on diagnostic accuracy or sensitivity of EBUS-TBNA. Abu-Hijleh et al.  found thGuidelines on training requirements for EBUS-TBNA, based on expert opinion, recommend at least 40–50 procedures for initial proficiency acquisition ,97. HoweUsually, for EBUS-TBNA and EUS-FNA, three to four aspirations per lymph node station are recommended, as the diagnostic yield curve reaches its plateau after three samples ,101,102.In overall, there are several bronchoscopic techniques available to obtain tissue samples for sarcoidosis diagnosis, although most of the evidence considers the diagnostic superiority of endosonographic techniques, such as EBUS-TBNA alone or in combination with EUS-FNA, over conventional bronchoscopic modalities, for Scadding stages I and II of the disease. The utility of endosonography procedures in the diagnosis of sarcoidosis cannot be neglected, but its usefulness as the only diagnostic procedure remains a challenge with concerns to the other stages of the disease. Though it is not always significantly superior to the standard bronchoscopic techniques, for optimal performance, the combined approach with TBLB and EBB is recommended. Moreover, TBLC may also have a role in sarcoidosis diagnosis, overcoming TBLB limitations, avoiding more invasive modalities and being complementary to endosonography procedures, such as EBUS-TBNA. In this context, the following diagnostic flowchart is proposed for bronchoscopic diagnosis of sarcoidosis .


Propionobacterium acnes (P. acnes) causing mediastinitis following EBUS-TBNA of a subcarinal lymph node.Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is now a standard of care to sample mediastinal lymph nodes and masses with high diagnostic accuracy and low complication rates. However, the procedure has potential complications that might be life-threatening. Here, we present the first case of  EBUS-TBNA has a pivotal role in diagnosing malignant and benign conditions within the chest. Moreover, it is more cost-effective when compared to mediastinoscopy that is considered gold standard. Real-time needle biopsies can be performed from lymph nodes or masses adjacent to the airway or from the lesions within the lung parenchyma. Besides complications related to bronchoscopy and conscious sedation, EBUS procedure may result in complications related to needle puncturing structures in the chest. These complications are rare and listed as infections , pneumothorax, and bleeding.A 57-year-old female with a history of hypothyroidism, hyperlipidemia, and glaucoma presented to the interventional pulmonology (IP) clinic for evaluation of lung nodules found incidentally on chest imaging for evaluation of chronic cough. Her dry cough had persisted for 4 months, and computed-tomography (CT) of the chest demonstrated right lower lobe clusters of noncalcified, solid nodules, largest measuring 10 × 15 mm, with an enlarged subcarinal lymph node (LN) measuring 1.4 × 2.8 cm . She den9/L, 76.9% neutrophils), and CT chest was significant for a large subcarinal mass measuring 5.5 × 2.6 cm causing mass effect on adjacent vessels and esophagus (Propionibacterium acnes (P. acnes). Fungal cultures, KOH stain, and AFB stain and culture were negative. Final histopathology showed fibroadipose tissue with fibrin, fat necrosis, and chronic inflammation consistent with abscess. There was no evidence of malignancy.Ten days later, she presented to the Emergency Room with complaints of a low-grade fever, shortness of breath, and sharp and posterior right-sided chest pain which worsened since the procedure. Her vital signs and physical examination were unremarkable. Initial laboratory work demonstrated a mild leukocytosis with left shift  became available and the combined modality of EBUS-TBNA has become first line for the evaluation of mediastinal lymphadenopathy. Since the advent of this technology, EBUS-TBNA has been a safe and well-tolerated procedure with a reported 24 hr complication rate of 1.4%. Although overall complications are rare, development of infectious complications including bacteremia, mediastinitis, pericarditis, and abscess formation following EBUS-TBNA is seldomly reported in the literature [P. acnes, initially discovered through the subcarinal biopsy had disseminated via inoculation of the biopsy needle. Although the benign nature of postbronchoscopy fever is well established, additional symptoms including pleuritic pain and dyspnea should be considered serious and include a thorough evaluation and a multidisciplinary approach as in this case which decidedly contributed to a full recovery. Uniquely, this is the only reported case of P. acnes abscess following EBUS-TBNA in an immunocompetent patient.In this current report, we highlight a rare complication following the most common procedure performed by interventional pulmonologists. Our hypothesis is that the pathogen, Mycobacterium tuberculosisn=1, Histoplasma capsulatumn=1, and Blastomyces dermatitidisn=1). Although there was no report of post-EBUS infections in our study, there are a total of 18 reported cases of mediastinal infectious complications following EBUS-TBNA with a mean time to infection of 18.1 days [Streptococcus species, C. albicans, P. acnes, Klebsiella pneumoniae, Gemella morbillorum, Prevotella buccae, Actinomyces, P. aeruginosa, and diptheroids.Currently, there are no accepted recommendations for prophylactic antibiotics with regard to EBUS-TBNA and current management is driven by clinical studies and experience informing expert opinion . Our ins8.1 days –9. Of thWhile a mechanism for this complication has not been elucidated, the primary hypothesis is via inoculation of oropharyngeal bacteria into the deep mediastinal tissue during needle puncture. Proposed risk factors include the increasing number of passes in the lymph node tissue, increasing number of samples per lymph node, operator expertise, puncture of a necrotic/cystic lesion , or contamination of the working channel ; however, there are no prospective data to support this . Other pEBUS-TBNA seems to be the optimal sampling modality for mediastinal and hilar lesions; however, serious complications can occur as described in this report. Although infectious complications related to EBUS-TBNA have been accepted to be a rare event, this may actually underscore the inadequacy of adverse event reporting or symptomatology recognition following these procedures. Although there is less certainty to the added benefit of prophylactic antibiotics prior to EBUS-TBNA in all comers, use of antibiotics in select patients where proposed risk factors for procedure-related disseminated infection may improve outcomes. In conclusion, this case demonstrates that post-EBUS infections do occur and may be underrecognized and development of severe symptoms should be identified and managed accordingly.