The Veterans Health Administration's Traumatic Brain Injury Screen and Evaluation: Service Delivery Insights.

BACKGROUND: In recognition of the incidence of traumatic brain injuries (TBIs) in the Iraq and Afghanistan conflicts, the Department of Veterans Affairs (VA) has, since 2007, examined returning U.S. service members for symptoms of TBI, a pre-condition for VA treatment of TBI. This study characterizes "Traumatic Brain Injury screen" service delivery, according to the barrier and facilitator viewpoints of those experiencing the delivery. METHODS: The purposeful sample comprised both Veteran patient and VA staff participants in the TBI screen program (n = 64), including patients (n = 14), health care providers (n = 38), and key informants (n = 12). Telephone interviews were conducted per standardized, semi-structured interview scripts; respondent narratives recorded and transcribed verbatim; natural emergence of key themes of discourse fostered through conventional content analysis; themes coded by meaning and meaning units organized by nature of influence on service delivery. RESULTS: A wide variety of structural, administrative, and communications barriers impede TBI screen service delivery, and certain case management and other functions promote delivery. CONCLUSIONS: The value of VA TBI screen service delivery is appreciated by its participants, but delivery is perceived as vulnerable to failure; the extent of such failure and short- and long-term effects on patient health and well-being outcomes is incompletely understood and merits investigation. Evaluating VA TBI screen service delivery under alternate modes of delivery, e.g., one-stop visits, expanded hours of delivery, shared appointment sessions, telehealth, and intensified case management is suggested.

Perceptions of practice guidelines for people with spinal cord injury.

PURPOSE: The Consortium for Spinal Cord Medicine published clinical practice guidelines (CPG) related to upper limb (UL) preservation in people with spinal cord injury (SCI) in 2005. The purpose of this qualitative research was to identify stakeholder agreement with recommendations, performance gaps, and barriers and facilitators to CPG implementation. DESIGN: This 6-month study focused on the perspectives of healthcare providers, veterans, and key informants. The Promoting Action on Research Implementation in Health Services (PARiHS) was used to frame the interview questions, analyze data from focus groups and interviews, and develop conclusions and recommendations. METHOD: SCI Centers at the Tampa, Seattle, and Hines Veterans' hospitals participated. The purposeful sample for the focus groups included 32 healthcare providers, 21 veterans with SCI, and 3 key informants. Analysis of qualitative data netted the percent of agreement with recommendations, performance gaps, and strategies for CPG implementation. FINDINGS: Content analysis of focus group data revealed that healthcare providers agreed or partially agreed with 20 (57%) of the 35 CSCM CPG on UL preservation of function. Agreement ranged from 100% for assessment to 28% for equipment use. Barriers for implementation related to administrative and system issues. CONCLUSION: Consideration of gaps, barriers, and facilitators to implementation will assist clinicians to target interventions to preserve UL function.

A framework for managing wandering and preventing elopement.

PURPOSE OF THE STUDY: A framework aids choice of interventions to manage wandering and prevent elopement in consideration of associated risks and mobility needs of wanderers. DESIGN AND METHODS: A literature review, together with research results, published wandering tools, clinical reports, author clinical experience, and consensus-based judgments was used to build a decision-making framework. RESULTS: Referencing a published definition of wandering and originating a clinical description of problematic wandering, authors introduce a framework comprising (1) wandering and related behaviors; (2) goals of wandering-specific care, (3) interpersonally, technologically, and policy-mediated wandering interventions, and (4) estimates of relative frequencies of wandering behaviors, magnitudes of elopement risk, and restrictiveness of strategies. IMPLICATIONS: Safeguarding wanderers from elopement risk is rendered person-centered and humane when goals of care guide intervention choice. Despite limitations, a reasoned, systematized approach to wandering management provides a basis for tailoring a specialized program of care. The need for framework refinement and related research is emphasized.

Mapping the maze of terms and definitions in dementia-related wandering.

PURPOSE: An operational definition of dementia-related wandering is proposed to aid in clinical recognition, to promote research precision and validity, and to provide a pathway toward standardization of language in wandering science. DESIGN AND METHODS: (1) One-hundred-and-eighty-three journal articles from multiple databases (Medline, OVID, CSA Journals, OCLC First Search, Google Scholar, PubMed, EBSCO) were reviewed to extract alternative terms and definitions for wandering or wandering-related behaviours; (2) terms and definitions were ordered alphabetically into a glossary; (3) a consensus approach was used to group glossary terms with related meanings into possible domains of wandering; (4) four domains (locomotion, drive, space and time) were found sufficient to encompass all wandering definitions; (5) wandering terms were placed into a conceptual map bounded by the four domain concepts and (6) a new provisional definition of wandering was formulated. RESULTS: An empirically-based, operational definition improves clinical and research approaches to wandering and explicates historical inattention to certain beneficial aspects of the behaviour. IMPLICATIONS: Adoption of the proposed operational definition of wandering behaviour provides a platform upon which dementia care may be improved and standardized language may evolve in wandering science.

Providers' perceptions of spinal cord injury pressure ulcer guidelines.

BACKGROUND/OBJECTIVE: Pressure ulcers are a serious complication for people with spinal cord injury (SCI). The Consortium for Spinal Cord Medicine (CSCM) published clinical practice guidelines (CPGs) that provided guidance for pressure ulcer prevention and treatment after SCI. The aim of this study was to assess providers' perceptions for each of the 32 CPG recommendations regarding their agreement with CPGs, degree of CPG implementation, and CPG implementation barriers and facilitators. METHODS: This descriptive mixed-methods study included both qualitative (focus groups) and quantitative (survey) data collection approaches. The sample (n = 60) included 24 physicians and 36 nurses who attended the 2004 annual national conferences of the American Paraplegia Society or American Association of Spinal Cord Injury Nurses. This sample drew from two sources: a purposive sample from a list of preregistered participants and a convenience sample of conference attendee volunteers. We analyzed quantitative data using descriptive statistics and qualitative data using a coding scheme to capture barriers and facilitators. RESULTS: The focus groups agreed unanimously on the substance of 6 of the 32 recommendations. Nurse and physician focus groups disagreed on the degree of CGP implementation at their sites, with nurses as a group perceiving less progress in implementation of the guideline recommendations. The focus groups identified only one recommendation, complications of surgery, as being fully implemented at their sites. Categories of barriers and facilitators for implementation of CPGs that emerged from the qualitative analysis included (a) characteristics of CPGs: need for research/evidence, (b) characteristics of CPGs: complexity of design and wording, (c) organizational factors, (d) lack of knowledge, and (e) lack of resources. CONCLUSIONS: Although generally SCI physicians and nurses agreed with the CPG recommendations as written, they did not feel these recommendations were fully implemented in their respective clinical settings. The focus groups identified multiple barriers to the implementation of the CPGs and suggested several facilitators/solutions to improve implementation of these guidelines in SCI. Participants identified organizational factors and the lack of knowledge as the most substantial systems/issues that created barriers to CPG implementation.