Cessation of group battlefield acupuncture visits due to COVID-19: a pilot study.

BACKGROUND: Prior to the COVID-19 pandemic, battlefield acupuncture (BFA) was offered to veterans with chronic pain in multidisciplinary group visits. OBJECTIVE: We aimed to assess the impact of cessation of BFA due to COVID-19 and to determine the utility of different aspects of the group visits for chronic pain management. METHODS: Participants who had attended at least three BFA group visits completed questionnaires assessing the impact of treatment interruption on pain, overall function and desire to resume treatment. RESULTS: Thirty-nine veterans were surveyed; 49% responded to the questionnaire. Ninety percent (17/19) agreed that BFA was an important part of pain management and that their pain had worsened after treatment interruption. Seventy-four percent (14/19) responded that they were taking more pain medications since BFA had ended. Ninety-five percent (18/19) responded that BFA improved daily function; 79% (15/19) agreed that BFA improved their sleep. Ninety-five percent (18/19) were interested in resuming BFA. Camaraderie was mentioned as the most helpful aspect of the group by 8/19 (42%) of participants. Participation of health psychology and nutrition were each mentioned as a most helpful aspect of the group by 5/19 (26%) of participants. CONCLUSION: Our results suggest that participants may have believed that BFA, camaraderie, and input from nutrition and health psychology services were important contributors to their pain control. The results also suggest that veterans may have suffered worsening pain, used more pain medications, and had worsening quality of sleep and daily function during the COVID-related clinic disruption, and that they were interested in resumption of the program.

Battlefield Acupuncture as a Treatment for Pain.

This study evaluated both randomized and nonrandomized trials of battlefield acupuncture for the treatment of both acute and chronic pain. Studies published between May 2016 and November 2019 were found through PubMed, the Cochrane Library, or Scopus, concerned with the treatment of pain using auricular acupuncture in accordance with battlefield acupuncture protocol. Search terms were battlefield acupuncture AND pain or auricular acupuncture AND pain. Case reports, literature reviews, meta-analyses, and expert opinions were not included. Bias risk was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. We found 12 studies with a combined sample size of 12,326. All five of the included nonrandomized trials reported positive outcomes, while five of seven of the included randomized trials reached statistical significance in their primary outcome. Six of the randomized trials were considered to have a high risk of bias resulting from the lack of blinding. The one randomized trial with moderate bias risk was a positive study. No severe adverse events were reported. Clinicians may consider battlefield acupuncture as a safe treatment for pain while the evidence base grows; however, we conclude that widespread adoption of battlefield acupuncture will require further high-quality studies drawing from diverse settings and patient populations. In addition, future studies should attempt to achieve blinding.

SARS-CoV-2 detection in setting of viral swabs scarcity: Are MRSA swabs and viral swabs equivalent?

BACKGROUND: The global pandemic of Severe Acute Respiratory Syndrome-Related Coronavirus 2 (SARS-CoV2) has resulted in unprecedented challenges for healthcare systems. One barrier to widespread testing has been a paucity of traditional respiratory viral swab collection kits relative to the demand. Whether other sample collection kits, such as widely available MRSA nasal swabs can be used to detect SARS-CoV-2 is unknown. METHODS: We compared simultaneous nasal MRSA swabs (COPAN ESwabs ® 480C flocked nasal swab in 1mL of liquid Amies medium) and virals wabs (BD H192(07) flexible mini-tip flocked nasopharyngeal swabs in 3mL Universal Transport Medium) for SARS-CoV-2 PCR testing using Simplexa COVID-19 Direct assay on patients over a 4-day period. When the results were discordant, the viral swab sample was run again on the Cepheid Xpert Xpress ® SARS-CoV-2 assay. RESULTS: Of the 81 included samples, there were 19 positives and 62 negatives in viral media and 18 positives and 63 negative in the MRSA swabs. Amongst all included samples, there was concordance between the COPAN ESwabs ® 480C and the viral swabs in 78 (96.3%). CONCLUSION: We found a high rate of concordance in test results between COPAN ESwabs ® 480C in Amies solution and BD H192(07) nasopharyngeal swabs in in 3 mL of Universal Viral Transport medium viral media. Clinicians and laboratories should feel better informed and assured using COPAN ESwabs ® 480C to help in the diagnosis of COVID-19.

Patient Feedback on the Effectiveness of Auricular Acupuncture on Pain in Routine Clinical Care: The Experience of 11,406 Veterans.

OBJECTIVES: Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective. RESEARCH DESIGN: In a cross-sectional cohort study, electronic medical record data for 11,406 Veterans treated with BFA at 57 VHA medical centers between October 2016 and September 2018 was analyzed. The multivariate analysis incorporated data on pain history, change in pain level on an 11-point scale, complications, and demographic information. METHODS: A total of 11,406 Veterans were treated with BFA at 57 VHA medical centers between October 2016 and September 2018 and had effectiveness data recorded in their electronic medical record. RESULTS: More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was -2.5 points (SD=2.2) at the initial BFA treatment, and -2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids. CONCLUSION: VHA's rapid expansion of training providers to offer BFA as a nonpharmacological approach to pain management has benefited many Veterans.

Disastrous Complication Caused Indirectly by the Success of Battlefield Acupuncture.

Background: Battlefield acupuncture (BFA) is an easy-to-learn type of auricular acupuncture that is being used increasingly and that has been shown to be effective for short-term reduction of pain. Many patients return for repeated applications of the semipermanent needles and ask if permanent earrings inserted in these points would lead to longer-lasting reduction in their pain. Case: A patient sought to have permanent earrings placed at his BFA auricular points. This 47-year-old man was referred for BFA for his chronic pain. He had several underlying health conditions. The BFA gave this patient good pain relief, but he had difficulty traveling to the VA center; this was why he wished to have the permanent earrings. Results: This patient had earrings implanted on his own where he thought the correct BFA points were. Hence, he developed a serious infection and inflammation that were difficult to treat. Conclusions: The patient tried to have permanent earrings, but they produced very deleterious effects. No recommendation for such implantations can be made at this time.

A Nervous Recipient of a "Tongue Lashing".

A veteran with a history of mental illness and drug and alcohol misuse developed a bleeding lesion on his tongue, which raised concerns of self-injury.

Hospital preparedness for COVID-19 pandemic: experience from department of medicine at Veterans Affairs Connecticut Healthcare System.

The 2019-2020 pandemic Coronavirus Disease 2019 (COVID-19) has inundated hospital systems globally, as they prepare to accommodate surge of patients requiring advanced levels of care. Pandemic preparedness has not been this urgently and widely needed in the last several decades. According to epidemiologic predictions, the peak of this pandemic has still not been reached, and hospitals everywhere need to ensure readiness to care for more patients than they usually do, and safety for healthcare workers who strive to save lives. We share our hospital-wide rapid preparedness and response to COVID-19 to help provide information to other healthcare systems globally.

Stethoscope hygiene: Using cultures and real-time feedback with bioluminescence-based adenosine triphosphate technology to change behavior.

BACKGROUND: Stethoscope hygiene is rarely done despite guideline recommendations. We wanted to determine whether demonstrating what is growing on the stethoscopes of providers via culture or bioluminescence technology alters perceptions and improves compliance. METHODS: Providers were given the opportunity to (1) culture their stethoscopes before and after disinfection with alcohol pads, alcohol-based hand rub, or hydrogen peroxide disinfectant wipes and (2) swab stethoscopes for bioluminescence-based adenosine triphosphate testing before and after disinfection. Outcomes were observed for hand and stethoscope hygiene rates and before and after intervention survey responses. The bacteria that were isolated, colony-forming units (CFU), and bioluminescence scores were tracked. RESULTS: A total of 1,245 observed hand hygiene opportunities showed that compliance improved from 72.5%-82.3% (P < .001). In addition, 590 observed patient-provider encounters revealed no significant change in stethoscope hygiene rates of 10% initially and 5% afterward (P = .08), although self-reported rates trended from 56%- 67% postintervention (P = .06). Perceptions regarding stethoscope hygiene importance improved (8.5/10 to 9.3/10; P = .04). Disinfection with alcohol pads, alcohol-based hand rub, and hydrogen peroxide disinfectant wipes were equivalent in CFU reduction (P = .21). CONCLUSIONS: Showing providers what is growing on their stethoscopes via cultures and bioluminescence technology before and after disinfection improved "buy in" regarding stethoscope hygiene importance. Both methods were rated as having an equal impact, however, objective observations failed to show improvement.

Challenges and Strategies for Implementing Battlefield Acupuncture in the Veterans Administration: A Qualitative Study of Provider Perspectives.

Objective: Battlefield Acupuncture (BFA) is an auricular needling protocol for pain. More than 1300 Veterans Health Administration (VHA) clinicians have been trained in BFA delivery. However, little is known about how well BFA has been implemented at the VHA. The aim of this research was to identify the challenges providers experience in implementing BFA and to look for any successful strategies used to overcome these challenges. Materials and Methods: Semistructured telephone interviews were conducted from June 2017 to January 2018, using an interview guide informed by the integrated Promoting Action on Research Implementation in Health Services framework to address several implementation domains: knowledge and attitudes about BFA; professional roles and training in BFA; organization of BFA delivery and resources to provide BFA; and implementation challenges and strategies to address challenges. The interviews were analyzed, using a grounded theory-informed approach. This research was conducted at 20 VHA facilities and involved 23 VHA BFA providers nationwide. Results: Nine main implementation themes were identified: (1) providers organizing BFA delivery in various ways; (2) insufficient time to provide BFA to meet patient demand; (3) beliefs and knowledge about BFA; (4) lack of BFA indication guidelines or effectiveness data; (5) self-efficacy; (6) time delay between training and practice; (7) limited access to resources; (8) key role of leadership and administrative buy-in, and (9) written consent an unwarranted documentation burden. Providers offered some possible strategies to address these issues. Conclusions: System- and provider-level challenges can impede BFA implementation. However, several providers discovered strategies to address some challenges that can be used within and outside the VHA, which, in turn, might improve access to this potentially promising pain-management intervention.

Group Battlefield Acupuncture in Primary Care for Veterans with Pain.

OBJECTIVE: To obtain preliminary data on the short- and intermediate-term effects of battlefield acupuncture (BFA) on self-reported pain intensity in a relatively large cohort of veterans to assess whether a more comprehensive clinical trial evaluation is warranted. METHODS: The treatment, in an outpatient group setting, consisted of up to five auricular semipermanent needles inserted into each ear at prespecified points. Efficacy of treatment was measured by self-reported pain, using the Defense and Veterans Pain Rating Scale, just before treatment and at posttreatment days 0, 1, 7, and 30. RESULTS: A total of 112 patients attended the group clinics. The mean pretreatment pain score was 6.8, with an immediate postprocedure decrease of 2.4 points. The proportion of patients reporting decreased pain was 88.4%, 80.7%, 52.4%, and 51% at posttreatment days 0, 1, 7, and 30, respectively. CONCLUSIONS: The short- and intermediate-term beneficial effect of BFA on chronic pain is clinically meaningful. The large proportion of patients reporting decreased pain even 30 days after treatment suggests that the long-term effect of BFA merits further investigation.

Auricular Acupuncture and Skin-Cancer Detection: An Opportunity.

Background: Auricular acupuncture is effective for many patients with pain. Many skin malignancies and precancerous lesions are found on the head and neck. Practitioners of acupuncture are in a unique situation to detect cutaneous malignancy at an early state. Case: An 83-year-old man referred for Battlefield Acupuncture was found to have a scalp lesion suspicious for malignancy as well as several precancerous lesions. Results: Referral to a dermatologist led to excision of a basal-cell cancer and treatment of actinic keratoses. Conclusions: Practitioners of auricular acupuncture should be familiar with common skin cancers and precancerous lesions; these practitioners are in a unique situation to detect these common skin lesions.

The "Hand-in" Project: Jump-starting Communication Between Inpatient and Outpatient Providers.

OBJECTIVES: Communication between hospitalists and primary care providers (PCPs) upon discharge has been much discussed, but the transition from outpatient to inpatient has received less attention. We questioned whether a brief, standardized e-mail from the hospitalist to the PCP upon admission could facilitate information exchange, increase communication, elucidate PCP preferences, and improve outcomes. METHODS: This prospective single-center study with a preintervention-to-postintervention design involved 300 inpatient admissions from June 2015 through October 2015 in the Veterans Affairs Connecticut Healthcare System. Hospitalists e-mailed an encrypted notification of admission along with standardized questions to PCPs within 1 day of admission. Measurements included the number of communications between PCPs and hospitalists, length of stay (LOS), 30-day readmissions, 30-day emergency department (ED) utilization rates, PCP preferences with regard to communication, and follow-up. RESULTS: Preintervention data for 94 patients during a 6-week period revealed 0.11 communications per patient, an LOS of 4.18 days, 30-day readmissions of 28.7%, and 30-day ED visits of 32%. Postintervention data on 206 patients during the next 12 weeks showed statistically significant increased communications per patient (0.5), and a nonsignificant decrease in LOS (3.96 days), 30-day readmissions (22.3%), and 30-day ED visits (31%). P values were <0.001, 0.67, 0.4, and 0.79, respectively. PCPs preferred e-mail communication upon discharge (40%) to telephone (25%) or instant messaging (13%), and 39% wanted a follow-up appointment within 2 weeks, regardless of what transpired. CONCLUSIONS: A hospitalist-led transition-of-care intervention designed to improve communication and information exchange between PCPs and hospitalists at the time of admission demonstrated that encrypted e-mail could be used as a tool to obtain useful additional medical and psychosocial information and to better understand PCP attitudes and preferences. The increased level of communication did not yield statistically significant decreases in LOS, 30-day readmission rates, or 30-day post-discharge ED visits, however.

Bedside Rounds Valued But Not Preferred: Perceptions of Internal Medicine Residents and Attending Physicians in a Diverse Academic Training Program.

OBJECTIVES: Bedside rounds/rounding (BDR) is an important tool for patient-centered care and trainee education. This study aimed at understanding the attitudes toward BDR among residents and attending physicians. METHODS: A survey was conducted using the Qualtrics survey tool. Responses were measured using a five-point Likert scale. RESULTS: The survey was sent to 301 attending physicians and 195 residents. Attending physicians conducted BDR 19% of the time. The preferred mode of rounding for residents was hallway and/or conference room rounding (67%). The major barriers to BDR were concern for causing confusion in or alarm to patients (attending physicians 49%, residents 77%) and prolongation of rounds (attending physicians 47%, residents 72%). The major advantages to BDR were increased likelihood of using patient-friendly language (attending physicians 84%, residents 69%) and the potential to improve trainees' oral presentations and physical examination skills (attending physicians 71%, residents 54%). Attending physicians reported having adequate skills to conduct BDR (95%) and potential opportunity to be better teachers with this mode of rounding (69%). Residents reported having some previous experience with BDR (46%) and agreed that BDR is an important skill for residents (62%). Only 34% of residents agreed that BDR allowed them to learn more about patient care compared with other modes of rounding, however. CONCLUSIONS: Our study showed that our participants perceive BDR positively. Endorsed benefits include the ability to use patient-friendly language, the potential to improve trainees' clinical skills, and an opportunity to become better teachers. The reported major barriers to BDR were potential concern for patient confusion and prolongation of rounds. Despite some prior exposure reported by residents and adequate attending skills, the frequency and preference for BDR remains low and the residents remain uncertain about the educational value of BDR. The evaluation of other factors that contribute to the low frequency of BDR needs further consideration. Furthermore, each residency program may differ in the patterns of perception toward BDR and these should be formally assessed before implementing this patient-centered mode of rounding.