Identifying Predictors of Airway Complications During Conscious Sedation Procedures.

Conscious sedation procedures are complicated by unanticipated airway compromise and obstruction. The STOP-Bang questionnaire (University of Toronto, 2012) is a validated obstructive sleep apnea screening questionnaire used as a preprocedure evaluation tool to assess a patient's risk for obstructive sleep apnea. The purpose of this study was to determine whether risk factors for obstructive sleep apnea, using the STOP-Bang questionnaire, could predict procedural airway complications in 152 endoscopy patients following conscious sedation. Logistic regression analysis revealed that a STOP-Bang score of greater than 5 (high risk) predicted a 10% change in heart rate (p = .021), apnea (p = .038), and arousal-relieved airway obstruction (p = .023). Every point of increase in body mass index predicted a 10% change in heart rate (p = .046), a drop in oxygen saturation (p = .002), apnea (p = .003), and 1.212 times the odds of requiring arousal-relieved airway obstruction (p = .002). An intermediate-risk STOP-Bang score (3-4) positively correlated to abnormal carbon dioxide values during the procedure (p = .015). These findings concur with existing literature on the topic and translate to clinical considerations of procedural monitoring protocols for patients with a high probability for airway complications during conscious sedation.

Music to reduce stress in hospitalized patients.

PURPOSE: To determine the impact of music on the physiologic and psychological stress experienced by hospital inpatients. METHODS: This pilot study monitored vital signs; utilized pain, anxiety, and agitation rating scales; and gathered verbal feedback from 50 participating inpatients at the authors' healthcare facility as they listened to music via an audiovisual interactive patient engagement technology system. RESULTS: After listening to music for 30 minutes, patients reported significantly lower pain and anxiety. CONCLUSION: Music offered a helpful tool to reduce pain and anxiety for patients in the ICU and telemetry units at the authors' healthcare facility. Future research may be geared toward incremental expansion and monitoring of this music intervention in other units.

Early lessons learned in implementing a women's health educational and virtual consultation program in VA.

BACKGROUND: Many Veterans Health Administration primary care providers (PCPs) have small female patient caseloads, making it challenging for them to build and maintain their women's health (WH) knowledge and skills. To address this issue, we implemented a longitudinal WH-focused educational and virtual consultation program using televideo conferencing. OBJECTIVE: To perform a formative evaluation of the program's development and implementation. RESEARCH DESIGN: We used mixed methods including participant surveys, semi-structured interviews, stakeholder meeting field notes, and participation logs. We conducted qualitative content analysis for interviews and field notes, and quantitative tabulation for surveys and logs. SUBJECTS: Veterans Health Administration WH PCPs. RESULTS: In 53 postsession surveys received, 47(89%) agreed with the statement, "The information provided in the session would influence my patient care." Among 18 interviewees, all reported finding the program useful for building and maintaining WH knowledge. All interviewees also reported that sessions being conducted during their lunch hour limited consistent participation. Logs showed that PCPs participated more consistently in the 1 health care system that provided time specifically allocated for this program. Key stakeholder discussions revealed that rotating specialists and topics across the breadth of WH limited submission of cases. CONCLUSIONS: Our WH education and virtual consultation program is a promising modality for building and maintaining PCP knowledge of WH, and influencing patient care. However, allocated time for PCPs to participate is essential for robust and consistent participation. Narrowing the modality's focus to gynecology, rather than covering the breadth WH topics, may facilitate PCPs having active cased-based questions for sessions.

Implementing an HIV Rapid Testing-Linkage-to-Care Project Among Homeless Individuals in Los Angeles County: A Collaborative Effort Between Federal, County, and City Government.

Objectives. We developed and implemented an HIV rapid testing-linkage-to-care initiative between federal and local government. Methods. We used mixed methodology; HIV testing data were collected on-site, and qualitative data were collected via telephone. We used postintervention stakeholder and staff interviews to evaluate barriers and facilitators to this initiative. Results. We tested 817 individuals. We identified and confirmed 7 preliminary HIV positive individuals (0.86% seropositivity), 5 of whom were linked to care. Mean testing cost was $48.95 per client; cost per positive result was $5714. Conclusions. This initiative can be used as a template for other health departments and research teams focusing on homelessness and mitigation of the HIV/AIDS epidemic.

HIV Rapid Testing in a VA Emergency Department Setting: Cost Analysis at 5 Years.

OBJECTIVES: To conduct a comprehensive cost-minimization analysis to comprehend the financial attributes of the first 5 years of an implementation wherein emergency department (ED) registered nurses administered HIV oral rapid tests to patients. METHODS: A health science research implementation team coordinated with ED stakeholders and staff to provide training, implementation guidelines, and support to launch ED registered nurse-administered HIV oral rapid testing. Deidentified quantitative data were gathered from the electronic medical records detailing quarterly HIV rapid test rates in the ED setting spanning the first 5 years. Comprehensive cost analyses were conducted to evaluate the financial impact of this implementation. RESULTS: At 5 years, a total of 2,620 tests were conducted with a quarterly mean of 131 ± 81. Despite quarterly variability in testing rates, regression analysis revealed an average increase of 3.58 tests per quarter. Over the course of this implementation, Veterans Health Administration policy transitioned from written to verbal consent for HIV testing, serving to reduce the time and cost(s) associated with the testing process. CONCLUSIONS: Our data indicated salient health outcome benefits for patients with respect to the potential for earlier detection, and associated long-run cost savings.

Teleconsultation and Training of VHA Providers on Transgender Care: Implementation of a Multisite Hub System.

BACKGROUND: The Veterans Health Administration (VHA) is piloting a national program providing teleconsultation and training to clinicians to increase knowledge and comfort with treating transgender veterans and to expand clinical capacity. This program is based on Project ECHO and uses specialist expertise to train and educate front-line clinicians. Over time, the front-line clinicians increase knowledge and skills, enabling them to provide care locally and obviate need for patient travel. This program is innovative in its national scope, interdisciplinary team model, and multihub structure. This article describes development of the program and initial results for the first cohort of learners. MATERIALS AND METHODS: Five interdisciplinary clinical teams participated in the 14-session, 7-month program. Most teams had some experience treating transgender veterans prior to participation. RESULTS: The teams completed at least 12 of 14 sessions. Thirteen of 33 participants completed an evaluation. In general, respondents found the teleconsultation program very helpful and credited the experience with improving their team functioning. Furthermore, respondents reported a significant increase in confidence to treat transgender veterans by the end of the program (59% versus 83%). We explored whether it is possible to recruit VHA clinical teams to participate in lengthy training on a low prevalence but complex condition. CONCLUSIONS: Early results support the feasibility and effectiveness of this national VHA teleconsultation and training program for transgender care. Lessons learned from the first group of learners have been applied to two concurrent groups with positive results.

HIV rapid testing in a Veterans Affairs hospital ED setting: a 5-year sustainability evaluation.

Routine HIV testing in primary care settings is now recommended in the United States. The US Department of Veterans Affairs (VA) has increased the number of patients tested for HIV, but overall HIV testing rates in VA remain low. A proven strategy for increasing such testing involves nurse-initiated HIV rapid testing (HIV RT). The purpose of this work was to use a mixed methodology approach to evaluate the 5-year sustainability of an intervention that implemented HIV RT in a VA emergency department setting in a large, urban VA medical center to reduce missed diagnostic and treatment opportunities in this vulnerable patient population. In-person semistructured interviews were conducted with providers and stakeholders. Interview notes were qualitatively coded for emerging themes. Quarterly testing rates were evaluated for a 5-year time span starting from the launch in July 2008. Findings indicate that HIV RT was sustained by the enthusiasm of 2 clinical champions who oversaw the registered nurses responsible for conducting the testing. The departure of the clinical champions was correlated with a substantial drop-off in testing. Findings also indicate potential strategies for improving sustainability including engaging senior leadership in the project, engaging line staff in the implementation planning from the start to increase ownership over the innovation, incorporating information into initial training explaining the importance of the innovation to quality patient care, providing ongoing training to maintain skills, and providing routine progress reports to staff to demonstrate the ongoing impact of their efforts.

Central implementation strategies outperform local ones in improving HIV testing in Veterans Healthcare Administration facilities.

BACKGROUND: Pilot data suggest that a multifaceted approach may increase HIV testing rates, but the scalability of this approach and the level of support needed for successful implementation remain unknown. OBJECTIVE: To evaluate the effectiveness of a scaled-up multi-component intervention in increasing the rate of risk-based and routine HIV diagnostic testing in primary care clinics and the impact of differing levels of program support. DESIGN: Three arm, quasi-experimental implementation research study. SETTING: Veterans Health Administration (VHA) facilities. PATIENTS: Persons receiving primary care between June 2009 and September 2011 INTERVENTION: A multimodal program, including a real-time electronic clinical reminder to facilitate HIV testing, provider feedback reports and provider education, was implemented in Central and Local Arm Sites; sites in the Central Arm also received ongoing programmatic support. Control Arm sites had no intervention MAIN MEASURES: Frequency of performing HIV testing during the 6 months before and after implementation of a risk-based clinical reminder (phase I) or routine clinical reminder (phase II). KEY RESULTS: The adjusted rate of risk-based testing increased by 0.4 %, 5.6 % and 10.1 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). During phase II, the adjusted rate of routine testing increased by 1.1 %, 6.3 % and 9.2 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). At study end, 70-80 % of patients had been offered an HIV test. CONCLUSIONS: Use of clinical reminders, provider feedback, education and social marketing significantly increased the frequency at which HIV testing is offered and performed in VHA facilities. These findings support a multimodal approach toward achieving the goal of having every American know their HIV status as a matter of routine clinical practice.

Implementation of nurse-initiated rapid HIV testing at high-prevalence primary care sites within the U.S. Veterans Affairs Health Care System.

Nurse-initiated HIV rapid testing (NRT) increases testing/receipt of results compared with traditional testing. We implemented NRT in primary care clinics at 2 Veterans Affairs hospitals.At site 1, 2364 tests were conducted; 5 HIV positives were identified. At site 2, 2522 tests were conducted; 9 HIV positives were identified. Success varied across demographic/clinical strata.

A provider participatory implementation model for HIV testing in an ED.

BACKGROUND: The Centers for Disease Control and Prevention recommends routine HIV screening for adults. OBJECTIVES: Community-based participatory research incorporates subjects in the design and conduct of research. We included nurses and physicians in the implementation of HIV rapid test use in the emergency department (ED). We explored the process, facilitators, and barriers. METHODS: We identified clinical champions and trained staff. Physicians obtained consent and ordered HIV testing; nurses performed rapid testing. Testing rates were tracked by electronic medical record. We conducted regular meetings between staff and researchers. Semistructured qualitative interviews with providers were conducted at 3 months. RESULTS: By week 15, we administered 121 tests. After the eligibility protocol evolved to incorporate ED nursing concerns regarding staffing limitations from a random sampling model to one focused on testing during nonpeak hours, the weekly number of tests increased. Eighteen percent of providers favored nontargeted HIV screening, 27% favored the current model of testing at nonpeak hours, 32% supported diagnostic testing, and 18% favored no testing or "other." Barriers include written consent, electronic documentation, time constraints, and belief that screening is not a core ED duty. Facilitators include ease of test administration, belief that ED patients are at higher risk, and flexibility to tailor screening efforts according to patient volume. CONCLUSIONS: The ED-based HIV testing is feasible within a Veterans Hospital Administration setting. Involvement of nursing in a community-based participatory research implementation model may facilitate staff acceptance of nontargeted HIV screening and be a mechanism to initiate administration of clinical preventive services to ED patients with limited primary care contact.

Exportability of an intervention to increase HIV testing in the Veterans Health Administration.

BACKGROUND: Exportability, or the dissemination of successful health services interventions from one site to another, must be demonstrated before systemwide implementation. METHODS: The effectiveness of a previously successful multicomponent intervention to increase rates of HIV testing in Veterans Health Administration (VHA) health care facilities among those without records of previous testing was evaluated in two other VHA facilities. Whereas the principle responsibility for the provider-activation component of the intervention was previously borne by research staff, nonresearch staff now took on these responsibilities. RESULTS: The annual rate of HIV testing among persons with documented risk factors for acquiring HIV infection increased by 5.8% and 16% after the end of the first year of implementation for the sites to which the project was newly exported and where nonresearch staff were responsible for implementation. In contrast, for the original implementation sites, where research staff played a major role in implementation, testing rates increased by 9.3% and 12.4%. There was no change in the rate of testing at a control site. At one site, HIV testing rates increased before implementation of the provider activation aspect of the intervention program. CONCLUSIONS: An intervention to increase HIV testing rates, which combines informatics, organizational support, and provider activation, can be successfully exported and implemented by nonresearch staff and may not require an extensive provider activation program. The resultant increases in HIV testing are similar to those seen in facilities where research staff play an active role. This work provides support for further efforts to refine this program to promote non-risk-based testing for HIV infection, as per current VHA policy and to more broadly implement this program.

Interactive internet-based clinical education: an efficient and cost-savings approach to point-of-care test training.

BACKGROUND: We successfully created and implemented an effective HIV rapid testing training and certification curriculum using traditional in-person training at multiple sites within the U.S. Department of Veterans Affairs (VA) Healthcare System. OBJECTIVE: Considering the multitude of geographically remote facilities in the nationwide VA system, coupled with the expansion of HIV diagnostics, we developed an alternate training method that is affordable, efficient, and effective. METHODS: Using materials initially developed for in-person HIV rapid test in-services, we used a distance learning model to offer this training via live audiovisual online technology to educate clinicians at a remote outpatient primary care VA facility. RESULTS: Participants' evaluation metrics showed that this form of remote education is equivalent to in-person training; additionally, HIV testing rates increased considerably in the months following this intervention. Although there is a one-time setup cost associated with this remote training protocol, there is potential cost savings associated with the point-of-care nurse manager's time productivity by using the Internet in-service learning module for teaching HIV rapid testing. If additional in-service training modules are developed into Internet-based format, there is the potential for additional cost savings. Our cost analysis demonstrates that the remote in-service method provides a more affordable and efficient alternative compared with in-person training. CONCLUSIONS: The online in-service provided training that was equivalent to in-person sessions based on first-hand supervisor observation, participant satisfaction surveys, and follow-up results. This method saves time and money, requires fewer personnel, and affords access to expert trainers regardless of geographic location. Further, it is generalizable to training beyond HIV rapid testing. Based on these consistent implementation successes, we plan to expand use of online training to include remote VA satellite facilities spanning several states for a variety of diagnostic devices. Ultimately, Internet-based training has the potential to provide "big city" quality of care to patients at remote (rural) clinics.

Continuous quadratus lumborum block as post-operative strategy for pain control in spinal fusion surgery.

BACKGROUND AND AIMS: Lumbar spinal fusions have post-operative pain levels that can be difficult to treat. The objective of this study was to determine if using bilateral quadratus lumborum (QL) nerve block catheters for lumbar fusions changes the patient's post-operative recovery experience by reducing opioid consumption, thereby limiting potential risks and side effects and reducing recovery time. METHODS: There were a total of 52 surgical lumbar fusion patients in this single-center, retrospective cohort review. In control Group A, there were 26 patients who received opioid regimens. In control Group B, there were 26 patients who received bilateral QL block catheters with breakthrough opioid regimens. Forty-eight hour post-operative opioid use in oral morphine milligram equivalents (MME) and length of stay (LOS) from the post-anaesthesia care unit to hospital discharge were examined. RESULTS: Group A had a mean MME of 307.62 ± 305.37 mg. Group B had a statistically significant lower mean total MME of 133.78 ± 152.66 mg (P = 0.012, α = 0.05). On an average, Group A required 2.3 times the MMEs than Group B. Group A had a mean LOS of 2.34 ± 1.87 days, whereas Group B had a lower mean LOS of 1.98 ± 0.51 days. This difference of 0.36 days was not statistically significant (P = 0.522, α = 0.05). CONCLUSION: Surgical lumbar fusion patients who received the QL block catheter had a lower opioid requirement compared to standard opioid regimens. The study was underpowered to detect a difference in LOS.

The impact of integrated HIV care on patient health outcomes.

BACKGROUND: Control of viral replication through combination antiretroviral therapy (cART) improves patient health outcomes. Yet many HIV-infected patients have comorbidities that pose social and clinical barriers to achieving viral suppression. Integration of subspecialty services into HIV primary care may overcome such barriers. OBJECTIVE: To evaluate effect of integrated HIV care (IHC) on suppression of HIV replication. RESEARCH DESIGN: A retrospective cohort study of HIV patients from 5 Veterans Affairs healthcare facilities 2000 to 2006. SUBJECTS: Patients with >3 months of follow-up, sufficient baseline HIV severity, on cART. MEASURES: We measured and ranked Integrated Care at the facilities. These rankings were applied to patient visits to form an index of IHC utilization. We evaluated effect of IHC utilization on likelihood of achieving viral suppression while on cART, controlling for demographic and clinical factors using survival analysis. RESULTS: : The 1018 HIV-infected patients eligible for analysis had substantial barriers to responding to cART: 93% had comorbidities with mean 3.2 comorbidities per patient (SD = 2.0); 52% achieved viral suppression in median 231 days (SD = 411.6). Patients visiting clinics that offered hepatitis, psychiatric, psychologic, and social services in addition to HIV primary care were 3.1 times more likely to achieve viral suppression than patients visiting clinics which offered only HIV primary care (hazard ratio = 3.1, P < 0.001). CONCLUSIONS: Patients who visited IHC clinics were more likely to achieve viral suppression while on cART. Future research should investigate which elements of Integrated Care are most associated with viral control and what role provider experience plays in this association.

Barriers and facilitators to routine HIV testing in VA primary care.

BACKGROUND: Approximately 21% of the 1.1 million HIV-infected persons in the United States are unaware of their HIV status. The Centers for Disease Control (CDC) recommend routine opt-out HIV testing for all patients aged 13-64. Yet little is known about patient and provider perspectives on routine HIV testing. OBJECTIVE: We sought to understand patient and provider perspectives on the adoption of routine HIV testing within the US Department of Veterans Affairs. DESIGN: We conducted four focus groups with patients and two focus groups with primary care providers to explore perceptions of, communication about, and barriers and facilitators to routine HIV testing in primary care. PARTICIPANTS: Convenience sample of patients and primary care providers at two geographically diverse Veterans' Affairs Medical Centers. APPROACH: We conducted grounded thematic analyses of transcribed audio-recordings of focus groups to identify major themes, identifying similarities and differences between patient and provider perspectives. MAIN RESULTS: Patients and providers concurred that implementation of routine HIV testing, treating HIV like other chronic diseases, and removing requirements for written informed consent and pre-test counseling were of benefit to patients and to public health. Patients, however, wished to have HIV testing routinely offered by providers so that they could decide whether or not to be tested. Veterans also stated that routinizing testing would help destigmatize HIV. Six steps to communicating about routine testing ("the 6 R's") were identified. CONCLUSIONS: Patients and providers appear ready for implementation of routine HIV testing. However, providers should use patient-centered communication strategies to ease patients' concerns about confidentiality and stigma associated with HIV disease.

Evaluation of the sustainability of an intervention to increase HIV testing.

BACKGROUND: Sustainability-the routinization and institutionalization of processes that improve the quality of healthcare-is difficult to achieve and not often studied. OBJECTIVE: To evaluate the sustainability of increased rates of HIV testing after implementation of a multi-component intervention in two Veterans Health Administration healthcare systems. DESIGN: Quasi-experimental implementation study in which the effect of transferring responsibility to conduct the provider education component of the intervention from research to operational staff was assessed. PATIENTS: Persons receiving healthcare between 2005 and 2006 (intervention year) and 2006 and 2007 (sustainability year). MEASUREMENTS: Monthly HIV testing rate, stratified by frequency of clinic visits. RESULTS: The monthly adjusted testing rate increased from 2% at baseline to 6% at the end intervention year and then declined reaching 4% at the end of the sustainability year. However, the stratified, visit-specific testing rate for persons newly exposed to the intervention (i.e., having their first through third visits during the study period) increased throughout the intervention and sustainability years. Increases in the proportion of visits by patients who remained untested despite multiple, prior exposures to the intervention accounted for the aggregate attenuation of testing during the sustainability year. Overall, the percentage of patients who received an HIV test in the sustainability year was 11.6%, in the intervention year 11.1%, and in the pre-intervention year 5.0% CONCLUSIONS: Provider education combined with informatics and organizational support had a sustainable effect on HIV testing rates. The effect was most pronounced during patients' early contacts with the healthcare system.

A Comparison of One- and Four-Open-Chart Access: No Change in Computerized Provider Order Entry Error Rates.

OBJECTIVE: To assess changes in computerized provider order entry error rates among providers who with less than 24-hour notice were switched from four-chart access to one-chart-only access. METHODS: An interrupted time series analysis of emergency medicine providers, hospitalists, and maternal child health providers was performed with pairwise comparison of computerized provider order entry error rates within and between specialties. This retrospective snapshot consisted of four phases. Phase 1 was the baseline 2 weeks where providers were privileged to work with up to four charts open. Phase 2 was the 2-week period where providers were limited to one-chart access. Phase 3 was the 2-week period where providers were returned to four-chart access. And phase 4 was a 2-week period 3 months following the end of phase 3. RESULTS: Analysis of the overall and specialty-stratified cohorts revealed no statistically significant differences in median computerized provider order entry error rates across the four phases (Wilcoxon signed-rank test, α = 0.05). However, statistically significant differences in median computerized provider order entry error rates were detected between the three specialties within each phase of the study (Kruskal-Wallis, p < 0.001). CONCLUSION: Allowing providers in select specialties to have access to four charts simultaneously does not increase their computerized provider order entry error rates. Significant differences in error rates between specialties suggest the need for further study of the use of standardized order sets, charting, and workflow variations.

A system-wide intervention to improve HIV testing in the Veterans Health Administration.

BACKGROUND: Although the benefits of identifying and treating asymptomatic HIV-infected individuals are firmly established, health care providers often miss opportunities to offer HIV-testing. OBJECTIVE: To evaluate whether a multi-component intervention increases the rate of HIV diagnostic testing. DESIGN: Pre- to post-quasi-experiment in 5 Veterans Health Administration facilities. Two facilities received the intervention; the other three facilities were controls. The intervention included a real-time electronic clinical reminder that encourages HIV testing, and feedback reports and a provider activation program. PATIENTS: Persons receiving health care between August 2004 and September 2006 who were at risk but had not been previously tested for HIV infection. MEASUREMENTS: Pre- to post-changes in the rates of HIV testing at the intervention and control facilities RESULTS: At the two intervention sites, the adjusted rate of testing increased from 4.8% to 10.8% and from 5.5% to 12.8% (both comparisons, p < .001). In addition, there were 15 new diagnoses of HIV in the pre-intervention year (0.46% of all tests) versus 30 new diagnoses in the post-intervention year (0.45% of all tests). No changes were observed at the control facilities. CONCLUSIONS: Use of clinical reminders and provider feedback, activation, and social marketing increased the frequency of HIV testing and the number of new HIV diagnoses. These findings support a multimodal approach toward achieving the Centers for Disease Control and Prevention's goal of having every American know their HIV status as a matter of routine clinical practice.

Expanding HIV rapid testing via point-of-care paraprofessionals.

HIV counselling and testing has traditionally been performed by highly trained professionals in clinical settings. With HIV rapid testing, a reliable and easy to use diagnostic tool, paraprofessionals can be trained to administer on-site HIV testing in a variety of non-traditional settings, broadening the HIV detection rates. Our objective was to create a robust and sustainable paraprofessional training module to facilitate off-site HIV rapid testing in non-clinical settings. Trainees attended a series of training sessions involving HIV education, rapid test instructions and communication techniques. After these sessions, trainees competently carried out HIV rapid testing in homeless shelters throughout the Los Angeles county. Agencies motivated to expand HIV screening programmes may use trained paraprofessionals to administer a full range of services (recruitment, pretest counselling, test administration, interpretation of results, post-test counselling and documentation) through this training model and enabling more highly trained healthcare providers to focus efforts on patients identified as HIV-positive.

Implementation of an ECHO-Based Program to Provide Geriatric Specialty Care Consultation and Education to Remote Primary Care Teams.

Targeting specific practice changes and working directly with patient aligned care teams to change practice may be more productive than telehealth for improving outcomes in older veterans.