Purpose:To detail the methodology for the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine Program Pragmatic Trial (MI-SIGHT 2) a follow-up to the original MI-SIGHT program that showed feasibility under ideal conditions and efficacy without a comparator. Patients and Methods:A pragmatic randomized controlled trial will compare rate of eye disease detected using the technology-based approach of the MI-SIGHT 2 program (intervention) vs standard optometric exam (control) in a Federally Qualified Health Center (FQHC) (n=900). Inclusion criteria are age ≥ 18 years and no acute eye symptoms. Exclusion criteria are pregnancy or cognitive impairment. The MI-SIGHT 2 intervention leverages technologies including autorefraction, pachymetry, optical coherence tomography, and external and fundus photography, in addition to care navigation support to access low-cost eyeglasses through an on-line retailer and support attendance at recommended follow-up. The primary outcome is detected eye disease as measured by an in-person optometrist exam (control) or by optometrist interpretation of the MI-SIGHT 2 technology-based protocol (intervention). The eye diseases targeted for detection include glaucoma/suspected glaucoma, visually significant cataract, and diabetic retinopathy. The secondary outcome is vision-related quality of life ascertained by survey six weeks after the initial study visit. The exploratory outcomes are program satisfaction and recommended follow-up completion. A cross-over design also will investigate within-person inconsistencies in diagnosis between arms by having participants undergo both screening approaches in randomized order. We will also determine accuracy of diagnoses by each protocol compared to a gold-standard diagnosis determined and adjudicated by glaucoma specialists. Two glaucoma specialist physicians will review all technology-based exams to assess the presence of eye diseases; a third glaucoma specialist physician will adjudicate when there is disagreement. Conclusion:This pragmatic trial will generate evidence to inform best practices for glaucoma and eye disease screening at community health centers.

PURPOSE:To report eye disease detection referral rates for in-office eye care across the Screening and Intervention for Glaucoma and eye Health through Telemedicine (SIGHT) Studies conducted in Alabama (AL-SIGHT), Michigan (MI-SIGHT), and New York City (NYC-SIGHT). METHODS:Individuals age ≥40 years who completed eye health screenings in federally qualified health centers, a free clinic, and affordable housing developments were included in the analysis. Visual acuity, intraocular pressure (IOP), and fundus photography were conducted across all sites and detection of eye diseases and referral rates are reported. Two-sample t-test and chi-square test (or Fisher's exact test) were used to compare continuous and categorical variables, respectively, between those referred and not referred. RESULTS:Of the 838 participants screened in AL-SIGHT, 2970 in MI-SIGHT, and 708 in NYC-SIGHT, referral rates for in-office eye care were 47.3%, 42.8%, and 66.1% respectively. Detection rates of glaucoma and glaucoma suspect in AL-SIGHT were 18.6%, MI-SIGHT were 24%, and NYC-SIGHT were 26.7%. Among those referred there were significantly more participants who identified as Black race, had high school or less education, were single/divorced/separated/widowed, retired or unable to work/disabled, insured with Medicare, or reported having diabetes, hypertension, or glaucoma (p < 0.05). CONCLUSION:The SIGHT Studies provide evidence that reaching underserved individuals at high-risk for eye diseases and providing telehealth-based eye health screenings in trusted community-based settings, led to high rates of eye disease detection and referral for in-office eye care.

PURPOSE:To investigate factors associated with 90-day vision in patients with microbial keratitis (MK). DESIGN:Multicenter prospective cohort study recruited patients with MK from the United States and India from July 23, 2020, through May 1, 2024, and followed them for 90 days. PARTICIPANTS:Individuals ≥ 15 years of age with MK of > 2 mm2 in stromal infiltrate area without prior corneal surgery or gluing, impending corneal perforation or keratoplasty, no light perception vision, current pregnancy, or incarceration. METHODS:Data on sociodemographics, history, symptoms, clinical measures, and best-corrected visual acuity (BCVA) (as logarithm of the minimum angle of resolution [logMAR] units) at initial and 90-day visits were gathered, with BCVA carried forward for those healed before 90 days. Features were summarized overall and by site. Site-stratified multivariable linear regression models were investigated for associations with 90-day BCVA. MAIN OUTCOME MEASURES:Ninety-day logMAR BCVA. RESULTS:Of 479 participants analyzed, after exclusions (n = 31) and participants without a 90-day BCVA (n = 52), participants had an average 90-day BCVA of 1.36 ± 1.40 logMAR in the United States (US) and 0.70 ± 0.99 logMAR in India (P < 0.0001). For the US, worse 90-day BCVA was associated with worse presenting BCVA (β = 0.05-logMAR per 0.1-logMAR unit increase in presenting BCVA; P < 0.0001), longer time until presentation (β = 0.01 per day; P < 0.0001), no contact lens use (β = 0.46; P = 0.0131), and larger stromal infiltrate area (bacterial: β = 0.02 per 1-mm2 [P = 0.0082]; fungal: β = 0.10 per 1-mm2 increase in area [P = 0.0002]; P = 0.0017 for interaction). For the India, worse 90-day BCVA was associated with worse presenting BCVA (β = 0.04 logMAR; P < 0.0001), longer delays to presentation (β = 0.03 per day; P = 0.0004), diabetes mellitus (β = 0.41; P = 0.0019), hypopyon (β = 0.27; P = 0.0083), no recent ocular trauma (β = 0.21; P = 0.0370), and larger stromal infiltrate area (fungal: β = 0.03 per 1-mm2 [P < 0.0001]; bacterial: nonsignificant β [P = 0.07]; P = 0.0001 for interaction). CONCLUSIONS:Initial vision, longer time until presentation, and larger infiltrate size conferred risk for worse 90-day BCVA, whereas other factors were unique. Systems to mitigate care delays and to support access care are needed would support clinicians and improve vision outcomes. FINANCIAL DISCLOSURE(S):Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Purpose To quantify time spent on eye disease screening, optical care, and care navigation tasks during the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program at a federally qualified health center (FQHC) in Michigan, with the goal of anticipating workforce needs to inform the scalability of similar programs in low-resource settings. Design Cross-sectional study. Methods Ophthalmic technicians recorded time spent with MI-SIGHT participants on eye disease screening tasks and optical care over 22 days from October 1 to October 31, 2023, and care navigation tasks over 22 days from December 4, 2023, to February 2, 2024. Eye disease screening tasks included a health history, measuring visual acuity, contrast sensitivity, intraocular pressure, pachymetry, taking external and fundus photos and macular and retinal nerve fiber layer optical coherence tomography images. Optical care tasks included refraction, ordering glasses, coordinating glasses pickups, dispensing and fitting glasses, and handling returns. Care navigation tasks included scheduling follow-up appointments, assisting with insurance, and providing medical interpretation and education. Minutes spent on tasks were summarized with descriptive statistics (mean, standard deviation, median, minimum, and maximum). Full-time equivalent (FTE) was calculated as the percentage of full-time hours over 22 days. Results 154 participants receiving care through the MI-SIGHT program were included. Technicians spent 21.4% of an FTE on eye disease screening, 23.6% on optical care, and 12.1% on care navigation, with remaining FTE spent on other tasks including outreach, study coordination and research (42.9%). Conclusions Integrating optical care and care navigation services within a free eye disease screening program is time-intensive but can help deliver comprehensive, accessible eye care to low-income populations. The MI-SIGHT program offers a model for expanding eye care services in FQHCs and improving vision outcomes for medically underserved communities. This study provides insights into personnel needs to guide the scaling of similar programs in low-resource settings. Precis The Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program offers a novel approach to eye care by providing free eye disease screenings, optical services, and care navigation at a federally qualified health center to improve vision outcomes and eye health in underserved communities. This time study provides workforce estimates to guide the scaling of similar comprehensive eye care programs in low-resource settings.

Background: Glaucoma is a chronic disease that affects 3 million Americans. Glaucoma is most often asymptomatic until very late in its course when treatment is more difficult and extensive peripheral vision loss has already occurred. Taking daily medications can mitigate this vision loss, but at least half of people with glaucoma do not take their prescribed medications regularly. The purpose of this study is to improve glaucoma medication adherence among those with medically treated glaucoma and poor self-reported adherence using the Support, Educate, Empower personalized coaching program. Methods/design: This study is a two-site randomized controlled trial enrolling 230 participants with poor self-reported glaucoma medication adherence. The trial has two arms, an intervention arm and a control arm. Participants in the intervention arm receive personalized glaucoma education and motivational interviewing-based coaching over 6 months from a trained non-physician interventionist for three in-person sessions with between visit phone calls for check-ins where current adherence level is reported to participants. Participants also can elect to have visual, audio, text or automated phone call medication dose reminders. Participants in the control arm continue usual care with their physician and receive non-personalized glaucoma educational materials via mail in parallel to the three in-person coaching sessions to control for glaucoma knowledge content. All participants receive a medication adherence monitor. The primary outcome is the proportion of prescribed doses taken on schedule during the 6-month period. The secondary outcome is glaucoma related distress. The exploratory outcome is intraocular pressure. Discussion: The personalized education and motivational-interviewing-based intervention that we are testing is comprehensive in that it addresses the wide range of barriers to adherence that people with glaucoma encounter. Leveraging a custom-built web-based application to generate the personalized content and the motivational-interviewing-based prompts to guide the coaching sessions will make this program both replicable and scalable and can be integrated into clinical care utilizing trained non-physician providers. Although this type of self-management support is not currently reimbursed for glaucoma as it is for diabetes, this trial could help shape future policy change should the intervention be found effective.

Supplemental Digital Content is available in the text. Precis: The Michigan Screening and Intervention for Glaucoma and eye Health through Telemedicine (MI-SIGHT) program leverages community-engaged research, telemedicine, and health coaching to overcome key logistical and psychosocial barriers to improve glaucoma screening in underserved communities. Purpose: To describe the methodology of the implementation and evaluation of the MI-SIGHT Program. Methods: The MI-SIGHT Program uses community engagement, telemedicine, and health coaching to overcome key logistical and psychosocial barriers to glaucoma identification and care among underserved populations. The MI-SIGHT Program will be evaluated in 2 community clinics: Hamilton Community Health Network, a federally qualified health center in Flint, Michigan, and the Hope Clinic, a free clinic in Ypsilanti, Michigan. A Community Advisory Board including the research team and health care providers, administrators, and patients from both clinics will guide program implementation. An ophthalmic technician at the community clinics will conduct screening tests for glaucoma and eye disease. The data will be transmitted through electronic health record to be reviewed by an ophthalmologist who will make recommendations for follow-up care. The ophthalmic technician will conduct a return visit to fit low-or no-cost glasses, help arrange follow-up with an ophthalmologist, and provide education. Those diagnosed with glaucoma or suspected glaucoma will be randomized to standard education or personalized glaucoma education and coaching. Costs will be assessed. Results: The authors hypothesize that the MI-SIGHT Program will detect a higher prevalence rate of glaucoma than that found in the general population, improve upon presenting visual acuity, enhance vision-related quality of life, and demonstrate that personalized glaucoma education and coaching improve adherence to follow-up care. Conclusion: The MI-SIGHT Program may serve as a model for glaucoma screening and care in high-risk communities.

ObjectiveTo understand patient and nurse views on usability, design, content, barriers and facilitators of hospital whiteboard utilisation in patient rooms.DesignMultimethods study.SettingAdult medical-surgical units at a quaternary care academic centre.ParticipantsFour hundred and thirty-eight adult patients admitted to inpatient units participated in bedside surveys. Two focus groups with a total of 13 nurses responsible for updating and maintaining the whiteboards were conducted.ResultsMost survey respondents were male (55%), ≥51 years of age (69%) and admitted to the hospital ≤4 times in the past 12 months (90%). Over 95% of patients found the whiteboard helpful and 92% read the information on the whiteboard frequently. Patients stated that nurses, not doctors, were the most frequent user of whiteboards (93% vs 9.4%, p<0.001, respectively). Patients indicated that the name of the team members (95%), current date (87%), upcoming tests/procedures (80%) and goals of care (63%) were most useful. While 60% of patients were aware that they could use the whiteboard for questions/comments for providers, those with ≥5 admissions in the past 12 months were significantly more likely to be aware of this aspect (p<0.001). In focus groups, nurses reported they maintained the content on the boards and cited lack of access to clinical information and limited use by doctors as barriers. Nurses suggested creating a curriculum to orient patients to whiteboards on admission, and educational programmes for physicians to increase whiteboard utilisation.ConclusionBedside whiteboards are highly prevalent in hospitals. Orienting patients and their families to their purpose, encouraging daily use of the medium and nurse–physician engagement around this tool may help facilitate communication and information sharing.

OBJECTIVES:Little is known about how physician diagnostic thinking unfolds over time when evaluating patients. We designed a case-based simulation to understand how physicians reason, create differential diagnoses, and employ strategies to achieve a correct diagnosis.METHODS:Between June 2017 and August 2018, hospital medicine physicians at two academic medical centers were presented a standardized case of a patient presenting with chest pain who was ultimately diagnosed with herpes zoster using an interview format. Case information was presented in predetermined aliquots where participants were then asked to think-aloud, describing their thoughts and differential diagnoses given the data available. At the conclusion of the interview, participants were asked questions about their diagnostic process. Interviews were recorded, transcribed, and content analysis was conducted to identify key themes related to the diagnostic thinking process.RESULTS:Sixteen hospital medicine physicians (nine men, seven women) participated in interviews and four obtained the correct final diagnosis (one man, three women). Participants had an average of nine years of experience. Overall, substantial heterogeneity in both the differential diagnoses and clinical reasoning among participants was observed. Those achieving the correct diagnosis utilized systems-based or anatomic approaches when forming their initial differential diagnoses, rather than focusing on life-threatening diagnoses alone. Evidence of cognitive bias was common; those with the correct diagnosis more often applied debiasing strategies than those with the incorrect final diagnosis.CONCLUSIONS:Heterogeneity in diagnostic evaluation appears to be common and may indicate faulty data processing. Structured approaches and debiasing strategies appear helpful in promoting diagnostic accuracy.

Purpose. Clinical pharmacists in primary care clinics can potentially help manage chronic pain and opioid prescriptions by providing services similar to those provided within their scope of practice to patients with diabetes and hypertension. We evaluated the feasibility and acceptability of a pharmacist-physician collaborative care model for patients with chronic pain. Methods. The program consisted of an in-person pharmacist consultation and optional follow-up visits over 4 months in 2 primary care practices. Eligible patients had chronic pain and a long-term prescription for opioids or buprenorphine or were referred by their primary care physician (PCP). Pharmacist recommendations were communicated to PCPs via the electronic medical record (EMR) and direct communication. Mixed-methods evaluation included baseline and follow-up surveys with patients, EMR review of opioid-related clinical encounters, and provider interviews. Results. Between January and October 2018, 47 of the 182 eligible patients enrolled, with 46 completing all follow-up; 43 patients (91%) had received opioids over the past 6 months. The pharmacist recommended adding or switching to a nonopioid pain medication for 30 patients, switching to buprenorphine for pain and complex persistent opioid dependence for 20 patients, and tapering opioids for 3 patients. All physicians found the intervention acceptable but wanted more guidance on prescribing buprenorphine for pain. Most patients found the intervention helpful, but some reported a lack of physician follow-up on recommended changes. Conclusion. The study demonstrated that comanagement of patients with chronic pain is feasible and acceptable. Policy changes to increase pharmacists' authority to prescribe may increase physician willingness and confidence to carry out opioid tapers and prescribe buprenorphine for pain.

BACKGROUNDApproaches of trainees to diagnosis in teaching hospitals are poorly understood. Identifying cognitive and system‐based barriers and facilitators to diagnosis may improve diagnosis in these settings.METHODSWe conducted a focused ethnography of trainees at 2 academic medical centers to understand the barriers and facilitators to diagnosis. Field notes regarding the diagnostic process (eg, information gathering, integration and interpretation, working diagnosis) and the work system (eg, team members, organization, technology and tools, physical environment, tasks) were recorded. Following observations, focus groups and interviews were conducted to understand the viewpoints, problems, and solutions to improve diagnosis.RESULTSBetween January 2016 and May 2016, four teaching teams (4 attendings, 4 senior residents, 9 interns, and 12 medical students) were observed for 168 hours. Observations of diagnosis during care led to identification of the following four key themes: (1) diagnosis is a social phenomenon, (2) data necessary to make diagnoses are fragmented, (3) distractions interfere with the diagnostic process, and (4) time pressures impede diagnostic decision‐making. These themes suggest that specific interventions tailored to the academic setting such as team‐based discussions of diagnostic workups, scheduling diagnostic time‐outs during the day, and strategies to “protect” learners from interruptions might prove to be useful in improving the process of diagnosis. Future studies that implement these ideas (either alone or within a multimodal intervention) appear to be necessary.CONCLUSIONDiagnosis in teaching hospitals is a unique process that requires improvement. Contextual insights gained from this ethnography may be used to inform future interventions.

Background Identifying characteristics associated with struggling healthcare organisations may help inform improvement. Thus, we systematically reviewed the literature to: (1) Identify organisational factors associated with struggling healthcare organisations and (2) Summarise these factors into actionable domains. Methods Systematic review of qualitative studies that evaluated organisational characteristics of healthcare organisations that were struggling as defined by below-average patient outcomes (eg, mortality) or quality of care metrics (eg, Patient Safety Indicators). Searches were conducted in MEDLINE (via Ovid), EMBASE, Cochrane Library, CINAHL, and Web of Science from database inception through February 8 2018. Qualitative data were analysed using framework-based synthesis and summarised into key domains. Study quality was evaluated using the Critical Appraisal Skills Program tool. Results Thirty studies (33 articles) from multiple countries and settings (eg, acute care, outpatient) with a diverse range of interviewees (eg, nurses, leadership, staff) were included in the final analysis. Five domains characterised struggling healthcare organisations: poor organisational culture (limited ownership, not collaborative, hierarchical, with disconnected leadership), inadequate infrastructure (limited quality improvement, staffing, information technology or resources), lack of a cohesive mission (mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity), system shocks (ie, events such as leadership turnover, new electronic health record system or organisational scandals that detract from daily operations), and dysfunctional external relations with other hospitals, stakeholders, or governing bodies. Conclusions Struggling healthcare organisations share characteristics that may affect their ability to provide optimal care. Understanding and identifying these characteristics may provide a first step to helping low performers address organisational challenges to improvement. Systematic review registration PROSPERO: CRD42017067367.

Background To evaluate the effectiveness of a brief mindfulness intervention on hand hygiene performance and mindful attention for inpatient physician teams. Design A pilot, pre-test/post-test randomised controlled mixed methods trial. Setting One academic medical centre in the USA. Participants Four internal medicine physician teams consisting of one attending, one resident, two to three interns and up to four medical students. Intervention A facilitated, group-based educational discussion on how mindfulness, as practised through mindful hand hygiene, may improve clinical care and practices in the hospital setting. Main outcomes and measures The primary outcome was hand hygiene adherence (percentage) for each patient encounter. Other outcomes were observable mindful moments and mindful attention, measured using the Mindfulness Attention Awareness Scale, from baseline to post-intervention, and qualitative evaluation of the intervention. Results For attending physicians, hand hygiene adherence increased 14.1% in the intervention group compared with a decrease of 5.7% in the controls (P=0.035). For residents, the comparable figures were 24.7% (intervention) versus 0.2% (control) (P=0.064). For interns, adherence increased 10.0% with the intervention versus 4.2% in the controls (P=0.007). For medical students, adherence improved more in the control group (4.7% intervention vs 7.7% controls; P=0.003). An increase in mindfulness behaviours was observed for the intervention group (3.7%) versus controls (0.9%) (P=0.021). Self-reported mindful attention did not change (P=0.865). Conclusions A brief, education-based mindfulness intervention improved hand hygiene in attending physicians and residents, but not in medical students. The intervention was well-received, increased mindfulness practice, and appears to be a feasible way to introduce mindfulness in the clinical setting. Future work instructing clinicians in mindfulness to improve hand hygiene may prove valuable. Trial registration number NCT03165799; Results.

Background Diagnosis requires that clinicians communicate and share patient information in an efficient manner. Advances in electronic health records (EHRs) and health information technologies have created both challenges and opportunities for such communication. Methods We conducted a multi-method, focused ethnographic study of physicians on general medicine inpatient units in two teaching hospitals. Physician teams were observed during and after morning rounds to understand workflow, data sharing and communication during diagnosis. To validate findings, interviews and focus groups were conducted with physicians. Field notes and interview/focus group transcripts were reviewed and themes identified using content analysis. Results Existing communication technologies and EHR-based data sharing processes were perceived as barriers to diagnosis. In particular, reliance on paging systems and lack of face-to-face communication among clinicians created obstacles to sustained thinking and discussion of diagnostic decision-making. Further, the EHR created data overload and data fragmentation, making integration for diagnosis difficult. To improve diagnosis, physicians recommended replacing pagers with two-way communication devices, restructuring the EHR to facilitate access to key information and improving training on EHR systems. Conclusions As advances in health information technology evolve, challenges in the way clinicians share information during the diagnostic process will rise. To improve diagnosis, changes to both the technology and the way in which we use it may be necessary.

: Background: Although certification by an accredited agency is often a practice prerequisite in health care, it is not required of vascular access specialists who insert peripherally inserted central catheters (PICCs). Whether certification is associated with differences in practice among inserters is unknown.PURPOSE:The purpose of this study was to gather information regarding whether certified and noncertified PICC inserters differ with respect to their practices and views about PICC use.METHODS:We conducted a national survey of vascular access specialists, identifying certified PICC inserters as those who had received board certification from the Association for Vascular Access, the Infusion Nurses Society, or both. The 76-item survey asked about PICC policies and procedures at respondents' facilities, use of insertion technologies, device management, management of complications, perceptions about PICC use, and relationships with other health care providers. Additional data about respondents, including years in practice and primary practice settings, were also gathered. Bivariable comparisons were made using χ tests; two-sided α with P ≤ 0.05 was considered statistically significant.RESULTS:Of the 1,450 respondents in the final sample, 1,007 (69%) said they were certified inserters and 443 (31%) said they were not. Significantly higher percentages of certified than noncertified inserters reported having practiced for five or more years (78% versus 54%) and having placed 1,000 or more PICCs (58% versus 32%). Significantly more certified than noncertified inserters also reported being the vascular access lead for their facility (56% versus 44%). Reported practice patterns for insertion, care, and management of PICCs varied based on certification status. Some evidence-based practices (such as the use of ultrasound to measure catheter-to-vein ratios) were more often reported by certified inserters, while others (such as the use of maximal sterile barriers during PICC insertion) were not. Asked about their perceptions of PICC use at their institution, certified inserters reported higher percentages of inappropriate insertion and removal than noncertified inserters.CONCLUSION:Certified PICC inserters appear to be a distinct group of vascular access specialists. A better understanding of how and why practices differ between certified and noncertified inserters is necessary to ensuring safer, high-quality patient care.

Background While the use of technologies such as ultrasound and electrocardiographic (ECG) guidance systems to place peripherally inserted central catheters (PICCs) has grown, little is known about the clinicians who use these tools or their work settings. Methods Using data from a national survey of vascular access specialists, we identified technology users as PICC inserters that: (a) use ultrasound to find a suitable vein for catheter placement; (b) measure catheter-to-vein ratio; and (c) use ECG for PICC placement. Individual and organizational-level characteristics between technology users versus non-users were assessed. Bivariable comparisons were made using Chi-squared or Fisher's exact tests; two-sided alpha with p<0.05 was considered statistically significant. Results Of the 2762 PICC inserters who accessed the survey, 1518 (55%) provided information regarding technology use. Technology users reported greater experience than non-technology users, with a higher percentage stating they had placed >1000 PICCs (55% vs. 45%, p<0.001). A significantly greater percentage of technology users also reported being certified in vascular access by an external agency than non-technology users (75% vs. 63%, p<0.001). Technology users were more often part of vascular access teams with ≥10 members compared to non-technology users (35% vs. 22%, p<0.001). Some practices also varied between the two groups: for example, use of certain securement devices and dressings differed between technology users and non-users (p<0.001). Conclusions Technology use by vascular access clinicians while placing PICCs is associated with clinician characteristics, work setting and practice factors. Understanding whether such differences influence clinical care or patient outcomes appears necessary.

Background: The presence and proliferation of vascular access nursing in hospital settings has been identified as a potential contributor to growing demand, and possible overuse, of peripherally inserted central catheters (PICCs).Objective: We examined vascular access nurses' perceived role related to use of PICCs and the association with appropriateness of PICC use in hospitals.Design: A web-based survey was administered to members of two vascular access professional organizations.Participants: Of 2762 potentially eligible respondents who accessed the link, 1698 (61%) completed the survey. This sample was further restricted to vascular access nurses who worked in a U.S. hospital (n=1147).Methods: Respondents were categorized based on perceived role: 1) an operator who inserts PICCs; 2) a consultant whose views are not valued by the care team (unvalued consultant); 3) a consultant whose views are valued by the care team (valued consultant). Facility and respondent characteristics, reported practices, leadership support and relationships with other providers were compared across groups using chi-squared tests and analysis of variance. Multivariable logistic regression was used to assess the association between perceived role and reported percentage of PICCs placed for inappropriate reasons.Results: Among the 1147 respondents, 210 (18%) viewed themselves as operators, 683 (59%) as valued consultants, 236 (21%) as unvalued consultants, and 18 (2%) could not be categorized. A significantly higher percentage (93%) of valued consultants reported that vascular access nurses placed the majority of PICCs at their facility, compared to operators (83%) or unvalued consultants (76%) (p < 0.001). After adjustment, compared with operators, valued consultants were significantly more likely to report that < 10% of PICCs at their facility were inserted for inappropriate reasons (OR 1.7, p = 0.002); the finding was reversed for unvalued consultants (OR 0.69, p = 0.06).Conclusions: Vascular access nurses and their perceived role as part of the healthcare team are associated with PICC use in hospitals. Strong inter-professional collaboration and respect may help ensure more appropriate use of PICCs. Published by Elsevier Ltd.