Federal practitioner : for the health care professionals of the VA, DoD, and PHS最新文献

Background: Veterans face specific risk factors for neurocognitive disorders. Providing them with comprehensive care for dementia and related neurocognitive disorders is a challenge as the population ages. There is a need for family-centered interventions, specialized expertise, and collaboration among clinicians and caregivers. The literature suggests that application of a transdisciplinary care model can address these needs and provide effective dementia care.

Observations: The Veterans Affairs Greater Los Angeles Healthcare System has employed existing expertise to create a conference-centered transdisciplinary model that responds to the US Department of Veterans Affairs directive for a dementia system of care. This model involves direct participation of behavioral neurology, geriatric psychiatry, geriatrics, neuropsychology, nursing, and social work. In this model, the social worker serves as a dementia care manager and, along with the nurse specialist, assures long-term management through follow-up and monitoring. Transdisciplinary interactions occur in a clinical case conference where each discipline contributes to the veteran's care. The team generates a final report on treating these veterans, the caregiver's needs, referral for psychosocial services, and plans for monitoring and follow-up.

Conclusions: This model could be a template of a program for implementing the Dementia System of Care across Veteran Affairs medical centers.

Background: Vancomycin is a commonly used antibiotic for the treatment of methicillin-resistant Staphylococcus aureus (MRSA), which requires therapeutic drug monitoring (TDM). Guidelines recommend targeting an individualized area under the curve/minimum inhibitory concentration (AUC/MIC) ratio of 400 to 600 mg × h/L to maximize efficacy and minimize the risk of acute kidney injury (AKI). Before these guidelines, the accepted method of vancomycin TDM was using trough levels alone. To our knowledge, no studies of veterans have compared the difference in AKI incidence and time in the therapeutic range between monitoring strategies.

Methods: This single-site, retrospective, quasi-experimental study was conducted at the Sioux Falls Veterans Affairs Health Care System. The primary endpoint was the difference in vancomycin-induced AKI incidence between the 2 groups.

Results: This study included 97 patients with 43 in the AUC/MIC group and 54 in the trough-guided group. The incidence of vancomycin-induced AKI was 2% in the AUC/MIC group and 4% in the trough group (P = .10). The incidence of overall AKI for AUC/MIC-guided and trough-guided TDM was 23% and 15% (P = .29), respectively.

Conclusions: We did not find a significant difference in the incidence of vancomycin-induced or overall AKI between AUC/MIC- and trough-guided TDM. However, this study did indicate that AUC/MIC-guided TDM of vancomycin may be more effective than trough-guided TDM regarding a quicker time to and higher overall time in the therapeutic range. These findings support the recommendation to transition to the use of AUC/MIC-guided TDM of vancomycin in the veteran population.

Background: Aerococcus urinae (A urinae), considered a rare pathogen, has been identified with increasing frequency in urine cultures. Only 8 cases of spondylodiscitis due to A urinae have been reported. Optimal treatment for invasive A urinae infection is undefined. However, the reported cases were treated successfully with diverse antibiotic regimen combinations, all including a β-lactam and beginning with at least 2 weeks of IV antibiotics.

Case presentation: A 74-year-old man presented to the emergency department after 2 weeks of midthoracic back pain, lower extremity weakness, gait imbalance, fatigue, anorexia, rigors, and subjective fevers. The patient was presumed to have discitis secondary to a urinary tract infection with possible pyelonephritis and was given empiric vancomycin and ceftriaxone. Spinal magnetic resonance imaging with contrast supported spondylodiscitis. Preliminary results from the admission blood and urine cultures showed gram-positive cocci in clusters.

Conclusions: A urinae urinary tract infection in the absence of obvious predisposing factors should prompt evaluation for urinary outflow obstruction. We suspect a review of a US Department of Veterans Affairs population might uncover a higher incidence of A urinae infection than previously suspected.

Background: The current gold standard for screening for colorectal cancer is colonoscopy, a procedure that depends on the quality of bowel preparation. In 2016, the Veterans Health Administration introduced Annie, a text message service to improve health care communication with patients. The Minneapolis Veterans Affairs Medical Center conducted a prospective, single center study to measure the impact of Annie text messaging on patient satisfaction and quality of bowel preparation for patients undergoing outpatient colonoscopy.

Methods: Patients undergoing colonoscopy were divided into 2 groups. The control group received standardized patient education and a phone call prior to procedure. The intervention group, consisting of all patients who agreed to enroll, received a 6-day Annie text messaging protocol consisting of key bowel preparation steps that started 5 days prior to their scheduled procedure. Bowel preparation quality was measured using the Boston Bowel Preparation Scale (BBPS) score.

Results: During the study period, 688 veterans were scheduled for outpatient colonoscopy: 484 veterans were in the control group, 204 veterans were in the intervention group, and 126 were surveyed. Annie text messaging instructions were associated with a higher BBPS score (8.2) compared with usual care (7.8); P = .007 using independent t test, and P = .002 using parametric independent t test. Patients also reported satisfaction with the Annie text messaging service.

Conclusions: There was a statistically significant improvement in the average BBPS score in veterans receiving Annie text messages compared with the routine care control group for outpatient colonoscopies.

Background: The US Department of Veterans Affairs My HealtheVet (MHV) patient portal is a secure online tool that provides patients access to personal health information. Although facilitators exist to encourage veteran registration, barriers to both adoption and use among veterans persist. This quality improvement project sought to improve veteran access to MHV.

Observations: Using Plan-Do-Study-Act (PDSA) methodology, we identified barriers to registration, evaluated processes for enrollment, and integrated a process improvement champion into a rural primary care clinic workflow. After 3 PDSA cycles, the integration of new processes resulted in increased enrollment and engagement with MHV. Fourteen veterans registered for MHV at the point-of-care in a 3-month time frame.

Conclusions: Use of a connected electronic health record platform and implementation of an MHV champion in the outpatient primary care setting improved rural veteran access to personal health information. Audit and feedback on processes that provide access to health information is an important strategy to narrow the gap between veterans who access patient portals and those who do not.

Background: Prolonged postoperative intensive care unit (ICU) stays are common after cardiac surgery and are associated with poor outcomes. There are few studies evaluating how risk factors associated with mortality may change during prolonged ICU stays or how mortality may vary with length of stay. We evaluated operative and long-term mortality in post-cardiac surgery patients after prolonged ICU stays at 7, 14, 21, and 28 days and factors associated with mortality.

Methods: We included University of Michigan Medical Center cardiac surgery patients with ≥ 7 postoperative days in the ICU. We determined factors associated with hospital mortality at 7, 14, 21, and 28 days of ICU stay using logistic regression, and among hospital survivors, we determined the factors associated with long-term mortality using Cox regression.

Results: Of 8309 ICU admissions from cardiac surgery, 1174 (14%) had ICU stays > 7 days. Operative mortality was 11%, 18%, 22%, and 35% for the 7-, 14-, 21-, and 28-day groups, respectively. Mechanical ventilation on the day of assessment was associated with increased odds ratios of operative mortality in all models. Of the 1049 (89%) hospital survivors, 420 (40%) died by late follow-up. Median (IQR) Cox model survival was 10.7 (0.7) years. Longer ICU stays, postoperative pneumonia, and elevated discharge blood urea nitrogen were associated with increased hazard of dying; whereas higher discharge platelet count and cardiac transplant were protective.

Conclusions: Both operative and late mortality increased as the duration of a ICU stay increased after cardiac surgery.