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.

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.

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.

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.

Interdisciplinary Transgender Veteran Care: Development of a Core Curriculum for VHA Providers.

Purpose: The Veteran's Health Administration (VHA) has created a training program for interdisciplinary teams of providers on the unique treatment needs of transgender veterans. An overview of this program's structure and content is described along with an evaluation of each session and the program overall. Methods: A specialty care team delivered 14 didactic courses supplemented with case consultation twice per month over the course of 7 months through video teleconferencing to 16 teams of learners. Each team, consisting of at least one mental health provider (e.g., social worker, psychologist, or psychiatrist) and one medical provider (e.g., physician, nurse, physician assistant, advanced practice nurse, or pharmacist), received training and consultation on transgender veteran care. Results: In the first three waves of learners, 111 providers across a variety of disciplines attended the sessions and received training. Didactic topics included hormone therapy initiation and adjustments, primary care issues, advocacy within the system, and psychotherapy issues. Responses were provided to 39 veteran-specific consult questions to augment learning. Learners reported an increase in knowledge plus an increase in team cohesion and functioning. As a result, learners anticipated treating more transgender veterans in the future. Conclusion: VHA providers are learning about the unique healthcare needs of transgender veterans and benefitting from the training opportunity offered through the Transgender Specialty Care Access Network-Extension of Community Healthcare Outcomes program. The success of this program in training interdisciplinary teams of providers suggests that it might serve as a model for other large healthcare systems. In addition, it provides a path forward for individual learners (both within VHA and in the community) who wish to increase their knowledge.

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.

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.

The role of evidence and context for implementing a multimodal intervention to increase HIV testing.

BACKGROUND: Increasing the use of routine preventive care such as HIV testing is important, yet implementation of such evidence-based clinical care is complex. The Promoting Action on Research Implementation in Health Services (PARiHS) model for implementation posits that implementation will be most successful when the evidence, context, and facilitation strategies are strong for the clinical practice. We evaluated the relative importance of perceived evidence, context, and facilitation of HIV testing during the implementation of a multimodal intervention in US Department of Veterans Affairs primary care clinics. METHODS: A multimodal intervention including clinical reminders (CRs), academic detailing--providing education sessions for providers--and social marketing to improve HIV testing was implemented in 15 VA primary care clinics in three regions. We conducted qualitative formative and process evaluations using semi-structured interviews with HIV lead clinicians, primary care lead clinicians, nurse managers, and social workers. Interviews were analyzed thematically to identify barriers and facilitators to implementation of HIV testing and how these were addressed by the intervention. Sites were then rated high, medium, or low on the dimensions of perceived evidence and the context for testing. We then assessed the relationship of these ratings to improvements in HIV testing rates found in earlier quantitative analyses. RESULTS: Sites that showed greatest improvements in HIV testing rates also rated high on evidence and context. Conversely, sites that demonstrated the poorest improvements in testing rates rated low on both dimensions. Perceptions of evidence and several contextual aspects resulted in both barriers and facilitators to implementing testing. Evidence barriers included provider perceptions of evidence for routine testing as irrelevant to their population. Contextual barriers included clinical reminder overload, insufficient resources, onerous consent processes, stigma, provider discomfort, and concerns about linking individuals who test positive to HIV treatment. While most barriers were ameliorated by the intervention, HIV stigma in particular regions and concerns about linkage to care persisted. CONCLUSIONS: Interventions to implement evidence-based practices such as HIV testing can be successful when utilizing proven quality improvement techniques. However, it is critical to address providers' perceptions of evidence and consider aspects of the local context in order to fully implement new routine clinical practices such as HIV testing.

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 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.

A five-year self-sustainability analysis of nurse-administered HIV rapid testing in Veterans Affairs primary care.

In 2008, nurse-administered HIV oral rapid testing (RT) was introduced at the Veterans Affairs Primary Care Clinic in Downtown Los Angeles. Analysis at five years revealed variable yet increasing rates of HIV RT at that facility despite the fact that no post-launch support was provided by the implementation team. Qualitative interviews among stakeholders conducted at five years revealed the pre-existing implementation practices endemic to this clinic that facilitated this unprecedented success (e.g. history of positive quality improvement implementations, leadership support, clinician involvement at each step of the process to facilitate empowerment, ownership and feasible customisation of the implementation, cohesive communication among clinicians and leadership, training, efficient supply pathway, progressive performance feedback and ongoing encouragement).

Sustaining nurse-rapid HIV testing in the U.S. Department of Veterans Affairs: lessons learned from a comparative evaluation.

Routine HIV testing in primary care is now recommended in the United States. The U.S. Department of Veterans Affairs (VA) has increased the number of patients tested for HIV, but overall HIV testing rates remain low. A promising intervention for increasing HIV testing is nurse-initiated rapid testing (NRT). The purpose of this study was to build upon our previous research by implementing NRT in primary care clinics at two geographically distinct VA medical centers, and then conduct an evaluation to identify the barriers and facilitators to implementing and sustaining it. Semistructured telephone interviews were conducted with providers and stakeholders at two VA medical centers, one each on the East Coast and in the Southwest. Fieldnotes were developed following each interview and qualitatively coded for emerging themes. Findings indicate NRT was well integrated in both settings. NRT took little time to conduct, was well received by patients, and did not disrupt clinical scheduling. However, there were some sustainability challenges, including difficulties using the electronic medical record, and the challenges of new care practice structures. Implementing NRT is feasible in VA primary care settings. However, organizational challenges should be taken into account for subsequent efforts to implement NRT in VA primary care settings.

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.

Implementation science in the real world: a streamlined model.

The process of quality improvement may involve enhancing or revising existing practices or the introduction of a novel element. Principles of Implementation Science provide key theories to guide these processes, however, such theories tend to be highly technical in nature and do not provide pragmatic nor streamlined approaches to real-world implementation. This paper presents a concisely comprehensive six step theory-based Implementation Science model that we have successfully used to launch more than two-dozen self-sustaining implementations. In addition, we provide an abbreviated case study in which we used our streamlined theoretical model to successfully guide the development and implementation of an HIV testing/linkage to care campaign in homeless shelter settings in Los Angeles County.

Some new speculative ideas about the "behavioral homeostasis theory" as to how the simple learned behaviors of habituation and sensitization improve organism survival throughout phylogeny.

This paper explores further the "behavioral homeostasis theory" (BHT) regarding the evolutionary significance for organism survival of the two simple non-associative rapidly learned behaviors of habituation and sensitization. The BHT postulates that the evolutionary function of habituation and sensitization throughout phylogeny is to rapidly maximize an organism's overall readiness to cope with new stimuli and to minimize unnecessary energy expenditure. These behaviors have survived with remarkable similarity throughout phylogeny from aneural protozoa to humans. The concept of "behavioral homeostasis" emphasizes that the homeostatic process is more than just maintaining internal equilibrium in the face of changing internal and external conditions. It emphasizes the rapid internal and external effector system changes that occur to optimize organism readiness to cope with any new external stimulus situation. Truly life-threatening stimuli elicit instinctive behavior such as fight, flee, or hide. If the stimulus is not life-threatening, the organism rapidly learns to adjust to an appropriate level of overall responsiveness over stimulus repetitions. The rapid asymptotic level approached by those who decrease their overall responsiveness to the second stimulus (habituaters) and those who increase their overall responsiveness to an identical second stimulus (sensitizers) not only optimizes readiness to cope with any new stimulus situation but also reduces unnecessary energy expenditure. This paper is based on a retrospective analysis of data from 4 effector system responses to eight repetitive tone stimuli in adult human males. The effector systems include the galvanic skin response, finger pulse volume, muscle frontalis and heart rate. The new information provides the basis for further exploration of the BHT including new predictions and proposed relatively simple experiments to test them.

Implementation of routine rapid HIV testing within the U.S. Department of Veterans Affairs Healthcare System.

Current HIV testing methods can be ineffective; patients often do not return for results. HIV rapid testing (RT) provides accurate results in 20 min. Patients find nurse-initiated HIV rapid testing (NRT) more acceptable than current testing methods and increases receipt of test results. Translating research findings into sustainable practice poses widely recognized implementation challenges. To ascertain effectiveness of NRT implementation, formative and process evaluations were conducted within the U.S. Department of Veterans Affairs Healthcare System (VA). Nurses and physicians at 2 VA medical centers were trained to administer RT. A preimplementation formative evaluation was conducted at Site 1. Process evaluations of ongoing RT activities were conducted at Site 2. Interviews were conducted with key informants. Content and thematic analysis was conducted on the field notes. A variety of barriers and facilitators were discovered that impacted the implementation of NRT. Findings indicate concerns regarding training and incorporating NRT into workflow. Process interviews indicated that training concerns could be alleviated through various means. Finally, interviewees highlighted that other clinic settings might be a more preferred setting for NRT than primary care. Findings are currently being used for the implementation of additional NRT interventions, and can also guide NRT adoption in other facilities.

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.