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

Background: Management of precision oncology testing imposes a substantial burden on pathology departments. As the number of tests continue to grow, developing more efficient processes will become even more important.

Observations: A consult process for anatomic pathology molecular testing offers a way to maximize efficiency. While use of such a consult has been reported, detailed descriptions of the steps involved to facilitate adoption and adaptation at prospective sites is lacking. This article describes a consult process that was implemented at the Kansas City Veterans Affairs Medical Center in 2021. Areas of inefficiency are identified and a target process map is presented.

Conclusions: The proposed consult process increases test utilization, ensures appropriateness of orders, standardizes reporting, and improves efficiency. Laboratory understaffing and growing demand for testing necessitate more efficient processes for pathology to manage the workload and maintain the highest quality of cancer care.

Background: Naloxone is the most frequently prescribed antidote for opioid overdose. More than one-third of opioid overdose reversals involved ≥ 2 doses of intranasal naloxone 4 mg. While an 8 mg intranasal product is available, there are limited recommendations for the preferred dosage. This study reviews and analyzes data to determine if there is a difference in prescribing patterns for naloxone 4 mg and naloxone 8 mg at Veteran Health Indiana (VHI).

Methods: Patients prescribed naloxone 4 mg or 8 mg at VHI between April 1, 2022, and April 1, 2023, were included. The primary endpoint was prescribing patterns between naloxone 4 mg and naloxone 8 mg. Data collected included naloxone prescriptions by month, number of patients with repeated naloxone fills, discipline of prescriber, type of clinic, and reason for receiving naloxone.

Results: One hundred one veterans were included in the study; 53.5% of veterans received a prescription for naloxone 8 mg, 41.6% for naloxone 4 mg, and 4.9% for both doses. Pharmacists prescribed the highest number of naloxone prescriptions regardless of dose, followed by nurse practitioners and physicians. Most naloxone prescriptions were written using the Stratification Tool for Opioid Risk Management initiative and primary clinics. Naloxone prescriptions were for chronic opioid use, opioid use disorder, and substance use disorder.

Conclusions: The absence of well-defined guidance regarding dosing for intranasal naloxone has led to disparate prescribing practices between prescriber disciplines, types of clinics, and indications for receiving naloxone. This study highlights the need for clinical guidelines with supporting evidence and institution-specific guidance.

Background: Excessive alcohol use is a leading cause of preventable death in the United States. Despite the availability of effective alcohol use disorder (AUD) treatments, usage remain low. This quality improvement project explored the use of direct-to-consumer (DTC) patient education across multiple US Department of Veterans Affairs (VA) facilities to increase AUD treatment.

Methods: Patients with AUD or at high risk for AUD at 5 Veterans Integrated Service Network (VISN) 21 sites who were not receiving AUD pharmacotherapy were identified. Veterans were eligible for inclusion if they had an Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) score ≥ 6 with an AUD diagnosis, or ≥ 8 without diagnosis, and a scheduled appointment with primary care, mental health, or a substance use disorder (SUD) health care practitioner between October 1, 2023, and January 31, 2024. The final cohort was mailed education materials about 2 weeks prior to their appointment. A comparator group from the previous year was identified using propensity score matching, and findings were assessed using logistic regression. The outcomes were assessed within 30 days of the scheduled visit, with the primary outcome being the initiation of pharmacotherapy and the secondary outcome being the placement of a consultation for mental health or SUD services.

Results: DTC education was mailed to 1260 veterans. Primary and secondary outcomes did not find statistically significant differences between patients that received DTC education and the comparator group (P > .59).

Conclusions: Although the results of this study were not statistically significant, this project initiated conversations at the VISN around AUD and available treatments. Future research should focus on addressing primary care involvement in AUD treatment, assessing different methods for delivering DTC education, and its potential long-term impact in the treatment of AUD.

Background: Store-and-forward teledermatology (SFT) involves sending clinical images and patient information to a dermatologist for evaluation and is widely used in US Department of Veterans Affairs (VA) Veterans Integrated Service Network 20. While SFT has increased access to dermatologic care, its impact on timely treatment is less well known. This study compares the timeline of care for melanoma treatment between SFT and face-to-face (FTF) dermatologic care and identifies potential areas for SFT improvement.

Methods: This study at the VA Puget Sound Health Care System included 107 patients in the FTF group and 87 patients in the SFT group. Electronic health record data were reviewed and key dates were extracted for patients in each group, including entry into episode of care (EEC), biopsy, and definitive excision. Median and mean intervals were compared between groups. To further analyze the groups, the FTF group was subdivided into where melanomas were entered into care, either at a dermatology clinic (FTF dermatology) or a primary care/nondermatology setting (FTF primary care).

Results: The median intervals from EEC to definitive excision for patients in the FTF and SFT groups were 58 and 73 days (P = .004), respectively. The median intervals from EEC to definitive excision in the FTF dermatology and FTF primary care groups were 37 and 78 days, respectively. Handoffs in SFT accounted for 6 to 12 days of the total timeline of care.

Conclusions: The fastest timeline of care for primary cutaneous melanoma is obtained when FTF dermatology is the EEC. The SFT timeline is significantly longer than that of FTF. Facilitating handoffs in SFT presents an opportunity for process improvement. The SFT timeline could be improved if the EEC, imaging, and SFT consultation requests all occurred on the same day.

Background: Prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) is an evidence-based psychotherapy (EBP) supported by multiple clinical practice guidelines. This article describes an innovative program delivering EBP PE therapy for veterans with PTSD.

Observations: The Intensive Virtual EBP Team (iVET) for PTSD was developed and implemented at the Veterans Affairs Pacific Islands Health Care System. iVET for PTSD is a 3-week telehealth program with 3 main components: (1) massed PE therapy for PTSD (4 sessions per week); (2) whole health and wellness classes (4 group sessions per week); and (3) individual health coaching to address personal wellness goals (1 session per week). In the initial 2.5 years of operation, the program had an 81% retention rate. Patients who participated in iVET for PTSD experienced significantly reduced PTSD, depression, anxiety, and substance use; improved quality of life; and reported high satisfaction with mental health care services. iVET for PTSD mental health care practitioners had increased compassion satisfaction and perceived support, and reduced burnout, secondary traumatic stress, and moral distress over the initial 6 months of providing massed PE in iVET.

Conclusions: Virtual massed PE therapy for a diverse veteran population with PTSD is feasible, acceptable, and effective, with high retention rates and patients reporting high satisfaction with mental health services. In addition, delivering PE for PTSD in a massed format is feasible and acceptable among staff and appears to contribute to improved job satisfaction and professional quality of life.

Background: Starting in October 2021, the Malcom Randall Veterans Affairs Medical Center Plastic Surgery Service began keeping patients undergoing hand surgery on the stretcher in the operating room (OR) as a time-saving initiative. The objective of this study was to evaluate this new process in terms of OR time efficiency, cost savings, and safety.

Methods: A retrospective chart review was conducted for hand surgery cases performed in the same OR by the same surgeon over 2 year-long periods: October 1, 2020, through September 30, 2021, when surgeries were performed on the OR table, and June 1, 2022, through May 31, 2023, when surgeries were performed on the stretcher. Time intervals obtained from the electronic medical record were "patient in OR" to "operation begin," "operation end" to "patient out OR," and "patient out OR" to next "patient in OR." The median times were compared between the periods. The Patient Safety and Employee Health offices were queried for reported patient or employee-patient transfer injuries. The Inventory Supply department provided the cost of materials used in the transfer process.

Results: A total of 306 hand surgeries were performed on a table and 191 were performed on a stretcher. The median time interval from in-room to operation begin was 25 minutes for the table and 23 minutes for the stretcher. The median time from operation end to patient out of OR was 4 minutes for the table and 3 minutes for the stretcher. Median room turnover time was 27 minutes for both time periods. There were no reported employee or patient injuries attributed to OR transfers during either time period. Supply cost savings was $111.28 per case when surgery was performed on the stretcher.

Conclusions: Hand surgery can be safely performed on the stretcher while reducing both time and costs. Over the course of a year, these savings can translate to $57,866 in supply costs and 26 hours of OR time.