despite its widespread use, the CAM was poorly understood by orthopaedic nurses at two academic institutions. The CAM may be difficult to implement in practice.

Background: Thyroid-stimulating hormone (TSH) is ordered commonly among inpatients, but the possibility of nonthyroidal illness syndrome challenges interpretation. Objective: Our objective was to obtain Canadian consensus on appropriate indications for ordering TSH in the first 48 h following presentation of a noncritically ill internal medicine patient. Design, Setting and Participants: Canadian endocrinologists with inpatient expertise were invited via snowball sampling to an online 3-round Delphi study. Main Outcome and Measures using a 6-point Likert scale, they rated 58 indications on appropriateness for measuring TSH in medical inpatients. These indications included clinical presentations, signs, and symptoms. Items that reached consensus and agreement (≥80% of participants selecting a rating of 5 or 6 on the Likert scale) were tabulated and dropped after each round. Qualitative analysis of comments identified additional contextual considerations as themes. Results: There were 45 participants (academic setting: 84%) representing 8 provinces (Ontario: 64%). Rounds 2 and 3 were completed by 42 and 33 participants, respectively. Nine indications reached consensus and agreement: presumed myxedema coma, presumed thyroid storm, atrial fibrillation/flutter, euvolemic hyponatremia, proptosis, adrenal insufficiency, hypothermia, thyroid medication noncompliance, and goiter. There was also agreement that two contextual considerations identified in thematic analysis, including a recent abnormal outpatient TSH, and the presence of other findings of thyroid dysfunction, would significantly change some mid-range responses. Conclusions: Canadian experts agreed upon nine specific indications for ordering an inpatient TSH, with others requiring consideration of previous TSH measurement and clinical context.

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