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

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.

Background: Pleural effusion, the presence of fluid within the pleural space, is a common condition secondary to a wide range of pathological causes. Splenic abscess, which is rare, has previously been described as a cause of exudative pleural effusion. Splenic abscess is thought to be associated with bacteremia, iatrogenic inoculation, or hematogenous spread from another bacterial focus. However, there are no documented cases of pleural effusion with the spleen as the source of infection.

Case presentation: An 80-year-old male presented with shortness of breath, weight loss, and fever. Imaging revealed a left pleural effusion and a splenic mass. Following several unsuccessful attempts to drain the effusion, attention shifted to the splenic mass, which proved to be a bacterial abscess. After targeted antibiotic treatment for the splenic abscess and surgical decortication for pleural adhesions, the patient showed significant improvement and was discharged.

Conclusions: This clinical scenario underscores the importance of identifying and addressing the source of pleural effusion, including consideration of splenic abscess as the primary process. By process of exclusion, we determined that the spleen was the origin of the disease, challenging the conventional perception of the spleen as exclusively a secondary locus of infection, without direct iatrogenic inoculation or bacteremia. The patient's presentation, hospital course, and response to treatment should encourage clinicians to consider a wider range of differential diagnoses for the primary pathologies underlying pleural effusions, facilitating earlier identification and intervention.

Background: Colorectal cancer screening rates at the Veterans Affairs Connecticut Healthcare System (VACHS) decreased during the COVID-19 pandemic. Fecal immunochemical testing is recognized as a tier 1 preferred screening method by the US Multi-Society Task Force on Colorectal Cancer. The VACHS implemented a program that mailed fecal immunochemical testing kits to patients to improve colorectal cancer screening rates.

Observations: This article describes the components of the VACHS patient aligned care team-based mailed fecal immunochemical testing program. Fecal immunochemical testing utilization, completion, and colorectal cancer screening rates at VACHS substantially increased after the implementation of this project.

Conclusions: Through a proactive, population-based colorectal cancer screening program centered on mailed fecal immunochemical testing kits outside of a traditional patient visit, VACHS substantially increased the utilization of fecal immunochemical testing kits as well as colorectal cancer screening rates.

Objective: To evaluate the clinical usefulness and costs of routine postoperative hematocrit testing after elective general surgery.

Methods: We reviewed charts of all patients who had elective general surgery at New Mexico Veterans Affairs Health Care System, Albuquerque hospital from 2011 through 2014. Demographic data and patient characteristics (eg, comorbidities, smoking/drinking history), estimated blood loss (EBL), pre- and postoperative hematocrit levels, and signs and symptoms of anemia were compared in patients who did or did not receive a blood transfusion within 72 hours of the operation.

Results: Of 1531 patients who had an elective general surgery between 2011 and 2014, ≥ 1 postoperative hematocrit levels were measured in 288 individual patients. There were 1312 postoperative hematocrit measurements before discharge (mean, 8.7; range, 1-44). There were 12 transfusions (0.8%) for patients without moderate to severe pre-existing anemia (hematocrit < 30%). Five of 12 transfused patients received intraoperative transfusions and 7 patients were transfused within 72 hours postoperation. No patients were transfused preoperatively. Of 12 patients receiving transfusion, 11 had EBL > 199 mL and/or signs of anemia. Risk factors for postoperative transfusion included lower preoperative hematocrit, increased EBL, and having either abdominoperineal resection or a total proctocolectomy.

Conclusions: Routine postoperative hematocrit measurements after elective general surgery at US Department of Veterans Affairs medical centers are of negligible clinical value and should be reconsidered. Clinical judgment, laboratory-documented pre-existing anemia, a high-risk operation, or symptoms of anemia should prompt monitoring of patient postoperative hematocrit testing. This strategy could have eliminated 206 initial hematocrit checks over the 4 years of the study.