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

Background: The US Department of Veterans Affairs (VA) is committed to conducting research that improves the health and quality of life of veterans. Mentorship is vital for developing and advancing a novice VA investigator's research agenda; however, there are several barriers to effective research mentorship.

Observations: The VA Clinical Research Mentorship Program was developed to assist clinician investigators with writing and submitting competitive grant applications. The program offers group and individualized consultation services utilizing the expertise of experienced investigators/faculty mentors, peer mentors, and other research staff. Since its inception in 2015, 35 clinicians have enrolled. Program mentees have submitted 33 grant proposals, with 19 approved for funding. Among participants who responded to a program evaluation survey, 17 reported (89%) that the meetings were an effective use of their time, 17 reported (89%) that the program increased their work satisfaction, and 13 reported (68%) that the program reduced clinician burnout.

Conclusions: A group-based research mentorship program was positively viewed by participants, proved to be successful in helping mentees obtain funding for research, and had an impact on increasing participants' work satisfaction and reducing levels of burnout.

Background: Antibiotic stewardship programs (ASPs) are multidisciplinary teams that optimize anti-infective use across health systems. The Veterans Health Administration mandates all facilities to implement ASPs and requires the development of ASP collaboratives in its regional Veterans Integrated Service Networks (VISNs).

Observations: The Veterans Affairs Sunshine Healthcare Network (VISN 8) serves > 1.5 million veterans across Florida, South Georgia, Puerto Rico, and the US Virgin Islands. Established in 2015, the VISN 8 ASP workgroup, serves as a model for ASP VISN collaboratives and includes ASP champions from each Veterans Affairs medical center within VISN 8 and meets monthly to review formulary issues, ongoing initiatives, antimicrobial use metrics, and other related topics. The VISN collaborative structure facilitates multisite quality initiatives, such as the implementation of area under the curve (AUC)-guided vancomycin dosing across 4 health care systems within VISN 8. AUC-guided dosing led to decreased rates of acute kidney injury compared with trough-based dosing (2.4% vs 10.4%) and the quality assurance evaluation identified best practices that could be disseminated across the VISN.

Conclusions: The VISN 8 ASP workgroup exemplifies how ASP champions can work together to solve common issues, complete tasks more efficiently, and impact large veteran populations. ASP collaboratives can leverage their collective size to complete robust multisite quality assurance evaluations. Expansion of the ASP collaborative model further highlights the Veterans Health Administration as a nationwide leader in ASP best practices.

Background: Home health agencies (HHAs) provide vital community-based services for older adults. Under-resourced HHAs that are disconnected from broader community emergency planning efforts may struggle to maintain services during emergencies. As climate-related disasters become more prevalent, HHA services are increasingly at risk, and policymakers have focused on the services they provide to older adults. This study explores the relationships between the Veterans Health Administration (VHA) and contracted HHAs to identify opportunities to extend VHA emergency resources to HHAs and staff to assist them during disasters.

Methods: We interviewed 19 stakeholders from 6 Veterans Affairs medical centers. Data were analyzed through rapid qualitative analysis.

Results: VHA and HHA staff focused primarily on their disaster response during emergencies with little knowledge of each other's protocols. VHA emergency managers lacked direct relationships with staff overseeing HHAs but had strong internal partnerships with clinicians and were knowledgeable about the needs of veterans who were disabled and homebound. VHA staff demonstrated an interest in partnering with HHAs to identify resources that could be shared during emergencies.

Conclusions: Creating a pipeline of support through existing relationships and resources has the potential to strengthen VHA protections for older adults during emergencies, help them age safely in place, and provide a model for other health systems to collaborate with community-based practitioners.

Case Presentation: A 65-year-old male veteran presented to the Veterans Affairs Boston Healthcare System (VABHS) emergency department with progressive fatigue, dyspnea on exertion, lightheadedness, and falls over the last month. New bilateral lower extremity numbness up to his knees developed in the week prior to admission and prompted him to seek care. Additional history included 2 episodes of transient loss of consciousness resulting in falls and a week of diarrhea, which had resolved. His medical history was notable for hypothyroidism secondary to Hashimoto thyroiditis, seizure disorder, vitiligo, treated hepatitis C virus (HCV) infection, alcohol use disorder in remission, diabetes mellitus, posttraumatic stress disorder, and traumatic brain injury. His medications included levothyroxine and carbamazepine. He previously worked as a barber but recently had stopped due to cognitive impairment. On initial evaluation, the patient's vital signs included a temperature of 36.3 °C, heart rate of 77 beats per minute, blood pressure of 139/83 mm Hg, respiratory rate of 18 breaths per minute, and 99% oxygen saturation while breathing ambient air. Physical examination was notable for a frail-appearing man in no acute distress. His conjunctivae were pale, and cardiac auscultation revealed a normal heart rate and irregularly irregular heart rhythm. A neurologic examination revealed decreased vibratory sensation in both feet, delayed and minimal speech, and a blunted affect. His skin was warm and dry with patchy hypopigmentation across the face and forehead. Laboratory results are shown in the Table. Testing 2 years previously found the patient's hemoglobin to be 11.4 g/dL and serum creatinine to be 1.7 mg/dL. A peripheral blood smear showed anisocytosis, hypochromia, decreased platelets, ovalocytes, elliptocytes, and rare teardrop cells, with no schistocytes present. Chest radiography and computed tomography of the head were unremarkable. An abdominal ultrasound revealed a complex hypoechoic mass with peripheral rim vascularity in the right hepatic lobe measuring 3.9 cm × 3.6 cm × 3.9 cm.

Background: The Veterans Health Administration (VHA) adopted the Age-Friendly Health Systems (AFHS) framework in March 2020, an initiative that complements whole health core principles. The shift from disease-based treatment to what matters most to veterans helps them improve their health and well-being.

Observations: Whole health and AFHS focus on holistic patient-centered care that aims to enhance the overall health and well-being of patients. Both approaches allow care teams to connect veterans with the most appropriate programs and services while also engaging in novel and impactful ways to align decision making to what matters to the patient and ensure continuum of care.

Conclusions: The combined efforts of whole health and AFHS ensure veterans are empowered and equipped to take charge of their health through assessments to identify their goals and care preferences, allowing their health services to be aligned with what matters most to them as patients. The VHA investment in this transformation empowers subject matter experts to collect data on implementation, scale up, and spread, and explore meaningful measures to monitor care quality and outcomes.

Background: Current evidence demonstrates that a significant proportion of prescriptions for antibiotics that originate from the emergency department (ED) are inappropriate. Urinary tract infections (UTIs) are a frequent indication for prescribing an antibiotic in the ED. The Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) piloted a pharmacistled ED aftercare program to promote appropriate antimicrobial management of outpatient UTIs.

Methods: A single center, retrospective chart review included veterans discharged with an oral antibiotic for UTI treatment from the VAGLAHS ED and evaluated by clinical pharmacists between June 1, 2021, and June 30, 2022. For patients with multiple ED visits, only the initial ED encounter was reviewed. Patients were excluded if they had a complicated UTI diagnosis requiring intravenous antibiotics or if they were admitted to the hospital.

Results: Of 449 veterans with an index UTI ED aftercare follow-up, 200 patients were evaluated. A cystitis diagnosis was made for 132 patients (66.0%) and 121 (60.5%) were empirically prescribed β-lactams. For 98 of 133 (73.6%) cases, appropriate empiric antibiotic selection led to no changes in index therapy. Sixty-seven cases required pharmacist intervention. Therapy modifications were made for 34 (17.0%) patients and 33 (16.5%) patients discontinued treatment. Discontinued therapy helped patients avoid 144 days of antibiotic exposure. Twelve (6.0%) patients had a subsequent urinary-related ED visit within 30 days.

Conclusions: Implementation of a pharmacist-driven UTI ED aftercare program at a US Department of Veterans Affairs medical center reduced unnecessary antimicrobial exposure and improved antibiotic management of UTIs.

Background: US Department of Veterans Affairs (VA) eligibility policies now allow comprehensive mental and behavioral health care services to be provided to veterans who received an Other Than Honorable (OTH) discharge upon separation from service. Research has shown a disproportionate mental health burden and elevated rates of criminal-legal involvement among these veterans. Eligibility policy shifts may impact programs and services designed to support veterans with criminal-legal involvement, such as veterans treatment courts.

Observations: Professionals serving veterans with criminal-legal involvement should become familiar with changes to VA eligibility policies and revise strategies, policies, and procedures surrounding the engagement and enrollment of veterans with OTH discharge characterizations. Veterans with OTH discharges often experience disproportionate mental health burdens and are overrepresented in judicial and correctional systems.

Conclusions: Professionals within judicial and correctional systems, particularly veterans treatment court programs, are encouraged to familiarize themselves with changes to VA eligibility policies and to revisit strategies, policies, and procedures surrounding the engagement and enrollment of veterans with OTH discharge characterizations into justice-focused programming and services.

Background: To establish a culture of safety and improve patient care, the Veterans Health Administration (VHA) is identifying and implementing necessary parameters and objectives across the health care landscape to enhance services on its journey to becoming a high reliability organization (HRO).

Methods: This quality improvement initiative sought to increase the understanding of factors that influence the establishment and sustainment of a just culture and identify specific methods for improving their implementation. Focus groups of HRO leads at 16 VHA hospital facilities identified emergent themes, facilitators, and barriers to maintaining a just culture and developed recommendations for enhancing both psychological safety and accountabilitity.

Results: The study identified the 5 key facilitators, barriers, and recommendations most frequently mentioned by HRO leads during focus group sessions. Implementing these strategies can potentially improve care standards and patient outcomes. Successfully integrating these recommendations demands consistent dedication, cooperation, and effort from stakeholders across all system levels, accompanied by regular evaluations to fortify the just culture principles.

Conclusions: This study offers an enriched perspective on initiating and sustaining a just culture and the broader application of HRO principles in health care. The methodology can act as a blueprint for broader HRO integration in the VHA and other institutions, particularly when paired with continuous quantitative evaluation of safety culture, just culture practices, and patient outcomes.

Background: Adenoma detection rate and interval colon cancer rates are associated with bowel preparation quality. The US Multisociety Task Force recommends repeat colonoscopy for individuals with inadequate bowel preparation (IBP) within 1 year. However, little is known regarding the rate and associated factors of repeat colonoscopy after IBP.

Methods: Individuals undergoing colonoscopy for screening, surveillance, positive fecal immunohistochemistry test, and virtual colonoscopy at the Minneapolis Veterans Affairs Medical Center from January 2016 to October 2021 were included. IBP was classified based on Boston Bowel Preparation Scale score or Aronchick scale.

Results: A total of 10,466 individuals were included, of which 571 (5.5%) had IBP. Repeat colonoscopy within 1 year was recommended for 485 individuals (84.9%); 287 (59.2%) were completed within this time period and 126 (26.0%) never underwent repeat colonoscopy. Proximity to the endoscopy center was associated with a higher rate of repeat colonoscopy within 1 year (61.7% vs 51.0%, P = .02). Current smoking status was associated with a lower rate of repeat colonoscopy within 1 year (25.8% vs 35.9%, P = .02). There were no differences in age, sex, race, inflammatory bowel disease diagnosis, or opioid or anticoagulation use with adherence to repeat colonoscopy within 1 year. There was no difference in adherence to a timely repeat colonoscopy from 1 year before the COVID-19 pandemic (58.9%) vs 1 year postpandemic (59.9%).

Conclusions: The rate of IBP was 5.5%. Only 59.2% of those with IBP underwent recommended repeat colonoscopy within 1 year, and 26.0% never underwent repeat colonoscopy. Additional efforts are needed to ensure that individuals with IBP return for timely repeat colonoscopy.