Michigan Market Referral Coordination Initiative: a Regional Market Approach to VA Specialty Care.

BACKGROUND: The Maintaining Internal Systems and Integrated Outside Networks (MISSION) Act of 2018 was created in response to reports of prolonged wait times for veterans accessing health care within the Veterans Affairs (VA) system. In Michigan, the MISSION Act Community Care Program led to an increased number of veterans receiving specialty care outside the VA system, in part due to the complicated process of coordinating specialty care within the VA system. From 2018 to 2020, the percentage of veterans referred to the VA Ann Arbor Healthcare System (AA) for specialty care from its two referring facilities, Battle Creek VA Medical Center (BC) and Saginaw VA Healthcare System (SAG), decreased from 54.4 to 27%. OBJECTIVE: Improve the number of Michigan veterans choosing VA specialty care. INTERVENTION: In 2021, three VA facilities in Michigan (AA, BC, and SAG) created a market-level referral system named the Michigan Market Referral Initiative (MMRCI). This unique approach used a centralized nurse-driven team to manage specialty referrals, working directly with the veteran to explore both VA and community care (CC) options. MAIN MEASURES: Referrals triaged and acceptance rates for VA care were tracked. The localized Standard Episode of Care model was used to estimate cost savings. Post-intervention AA patient wait times were compared to local CC wait times. KEY RESULTS: In the 14 months after implementation of the MMRCI, the rate of veteran retention increased by 32.4%. The estimated dollars retained within the VA by MMRCI efforts was $24,105,251 as of 7/1/2022. Post-intervention AA wait times were superior to community care except in 3 specialties. CONCLUSIONS: This multifacility effort is an example of a highly coordinated, veteran-centered collaboration that has led to successful retention of veterans within the VA system with resultant large-scale cost avoidance and comparable clinic wait times. Focusing on central care coordination and veteran engagement in the referral process are keys to its success, along with leveraging existing referral patterns between nearby VA facilities. This model could be extrapolated to other VA markets throughout the country where similar relationships exist.

Comparison of the Impact of COVID-19 on Veterans Affairs and Non-federal Hospitals: a Survey of Infection Prevention Specialists.

BACKGROUND: As the COVID-19 pandemic evolves, it is critical to understand characteristics that have allowed US healthcare systems, including the Veterans Affairs (VA) and non-federal hospitals, to mount an effective response in the setting of limited resources and unpredictable clinical demands generated by this system shock. OBJECTIVE: To compare the impact of and response to resource shortages to both VA and non-federal healthcare systems during the COVID-19 pandemic. DESIGN: Cross-sectional national survey administered April 2021 through May 2022. PARTICIPANTS: Lead infection preventionists from VA and non-federal hospitals across the US. MAIN MEASURES: Surveys collected hospital demographic factors along with 11 questions aimed at assessing the effectiveness of the hospital's COVID response. KEY RESULTS: The response rate was 56% (71/127) from VA and 47% (415/881) from non-federal hospitals. Compared to VA hospitals, non-federal hospitals had a larger average number of acute care (214 vs. 103 beds, p<.001) and intensive care unit (24 vs. 16, p<.001) beds. VA hospitals were more likely to report no shortages of personal protective equipment or medical supplies during the pandemic (17% vs. 9%, p=.03) and more frequently opened new units to care specifically for COVID patients (71% vs. 49%, p<.001) compared with non-federal hospitals. Non-federal hospitals more frequently experienced increased loss of staff due to resignations (76% vs. 53%, p=.001) and financial hardships stemming from the pandemic (58% vs. 7%, p<0.001). CONCLUSIONS: In our survey-based national study, lead infection preventionists noted several distinct advantages in VA versus non-federal hospitals in their ability to expand bed capacity, retain staff, mitigate supply shortages, and avoid financial hardship. While these benefits appear to be inherent to the VA's structure, non-federal hospitals can adapt their infrastructure to better weather future system shocks.

Effect of monoclonal antibody therapy on the endogenous SARS-CoV-2 antibody response.

Monoclonal antibody treatment of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection has been widely implemented. Effects of treatment on the endogenous primary humoral response to the virus are unknown. A retrospective cohort study performed at a Veterans Health Administration medical center compared serologic responses of treated and untreated COVID-19 patients at high risk for severe outcomes. Three anti-viral spike protein IgG monoclonal treatments were used during the study period, 1) bamlanivimab, 2) casirivimab with imdevimab, and 3) bamlanivimab with etesevimab. Data were analyzed at acute (0-9 days), seroconversion (10-19 days), and maximum antibody (20-39 days) stages. SARS-Cov-2 infection induced a dynamic primary humoral response with anti-spike IgM and anti-nucleocapsid IgG seroconversion occurring after 9 days with maximum serologic indices achieved by 20-39 days. All monoclonal antibody treatments suppressed the endogenous anti-spike IgM response by 85-90% with minor effect on the anti-nucleocapsid response. Thus, passive immunization therapy may cause immunologic interference.

Midline catheters: A 3-year experience at a veterans administration medical center.

BACKGROUND: Midline catheters are recommended over peripherally inserted central catheters as short-term vascular access device for peripherally compatible infusates. We assessed the effectiveness and safety of midline catheters. METHODS: Data from midline catheter placements from June 2016 to May 2019 at a tertiary-care Veterans Administration medical center were retrospectively collected. Patients were followed until catheter removal or death, whichever occurred first. The primary outcome was completion of intended therapy; secondary outcomes were catheter-related complications, including major (eg, catheter-related bloodstream infections [CRBSI] or venous thromboembolism [VTE]) and minor (eg, catheter occlusion, kinking, dislodgement) events. RESULTS: Of 115 midlines, 62 (53.9%) were for antibiotic infusion and 49 (32.6%) for difficult access. The median dwell time was 11 days (interquartile range, 5.5-19.5 days). Midline catheters lasted through completion of therapy in 93 patients (80.9%). Catheter-related complications occurred in 27 patients (23.5%), including catheter dislodgement in 10 patients (8.7%), catheter kinking in 8 (7.0%), and catheter occlusion in 3 (2.6%). Only 1 patient experienced a major complication, a deep venous thrombosis (0.9%). CONCLUSIONS: Midlines appear to be effective and safe for short-term vascular access in patients requiring peripherally compatible infusates. While the rate of major complications is low, minor complications that necessitate device removal are common.

Adverse outcomes of SARS-CoV-2 infection with delta and omicron variants in vaccinated versus unvaccinated US veterans: retrospective cohort study.

OBJECTIVES: To determine the association between covid-19 vaccination types and doses with adverse outcomes of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection during the periods of delta (B.1.617.2) and omicron (B.1.1.529) variant predominance. DESIGN: Retrospective cohort. SETTING: US Veterans Affairs healthcare system. PARTICIPANTS: Adults (≥18 years) who are affiliated to Veterans Affairs with a first documented SARS-CoV-2 infection during the periods of delta (1 July-30 November 2021) or omicron (1 January-30 June 2022) variant predominance. The combined cohorts had a mean age of 59.4 (standard deviation 16.3) and 87% were male. INTERVENTIONS: Covid-19 vaccination with mRNA vaccines (BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna)) and adenovirus vector vaccine (Ad26.COV2.S (Janssen/Johnson & Johnson)). MAIN OUTCOME MEASURES: Stay in hospital, intensive care unit admission, use of ventilation, and mortality measured 30 days after a positive test result for SARS-CoV-2. RESULTS: In the delta period, 95 336 patients had infections with 47.6% having at least one vaccine dose, compared with 184 653 patients in the omicron period, with 72.6% vaccinated. After adjustment for patient demographic and clinical characteristics, in the delta period, two doses of the mRNA vaccines were associated with lower odds of hospital admission (adjusted odds ratio 0.41 (95% confidence interval 0.39 to 0.43)), intensive care unit admission (0.33 (0.31 to 0.36)), ventilation (0.27 (0.24 to 0.30)), and death (0.21 (0.19 to 0.23)), compared with no vaccination. In the omicron period, receipt of two mRNA doses were associated with lower odds of hospital admission (0.60 (0.57 to 0.63)), intensive care unit admission (0.57 (0.53 to 0.62)), ventilation (0.59 (0.51 to 0.67)), and death (0.43 (0.39 to 0.48)). Additionally, a third mRNA dose was associated with lower odds of all outcomes compared with two doses: hospital admission (0.65 (0.63 to 0.69)), intensive care unit admission (0.65 (0.59 to 0.70)), ventilation (0.70 (0.61 to 0.80)), and death (0.51 (0.46 to 0.57)). The Ad26.COV2.S vaccination was associated with better outcomes relative to no vaccination, but higher odds of hospital stay and intensive care unit admission than with two mRNA doses. BNT162b2 was generally associated with worse outcomes than mRNA-1273 (adjusted odds ratios between 0.97 and 1.42). CONCLUSIONS: In veterans with recent healthcare use and high occurrence of multimorbidity, vaccination was robustly associated with lower odds of 30 day morbidity and mortality compared with no vaccination among patients infected with covid-19. The vaccination type and number of doses had a significant association with outcomes.

Vaccine breakthrough infections in veterans hospitalized with coronavirus infectious disease-2019: A case series.

BACKGROUND: While Severe Acute Respiratory Syndrome Coronavirus-2 vaccine breakthrough infections are expected, reporting on breakthrough infections requiring hospitalization remains limited. This observational case series report reviewed 10 individuals hospitalized with vaccine breakthrough infections to identify patient risk factors and serologic responses upon admission. METHODS: Electronic medical records of BNT162b2 (Pfizer-BioNTech) or mRNA-1732 (Moderna) vaccinated patients admitted to Veterans Affairs Ann Arbor Healthcare System with newly diagnosed Coronavirus Infectious Disease 2019 (COVID-19) between March 15, 2021 and April 15, 2021 were reviewed. Patient variables, COVID-19 lab testing including anti-S IgM, anti-N IgG antibodies, and hospital course were recorded. Based on lab testing, infections were defined as acute infection or resolving/resolved infection. RESULTS: Of the 10 patients admitted with breakthrough infections, all were >70 years of age with multiple comorbidities. Mean time between second vaccine dose and COVID-19 diagnosis was 49 days. In the 7 individuals with acute infection, none had observed serologic response to mRNA vaccination, 5 developed severe disease, and 1 died. Three individuals had anti-N IgG antibodies and a high polymerase chain reaction cycle threshold value, suggesting resolving/resolved infection. CONCLUSIONS: Given the variability of vaccine breakthrough infections requiring hospitalization, serologic testing may impart clarity on timing of infection and disease prognosis. Individuals at risk of diminished response to vaccines and severe COVID-19 may also benefit from selective serologic testing after vaccination to guide risk mitigation strategies in a post-pandemic environment.

SARS-CoV-2 Anti-Spike IgG Antibody and ACE2 Receptor Binding Inhibition Levels among Breakthrough Stage Veteran Patients.

SARS-CoV-2 mRNA vaccines have been critical to curbing pandemic COVID-19; however, a major shortcoming has been the inability to assess levels of protection after vaccination. This study assessed serologic status of breakthrough infections in vaccinated patients at a Veterans Administration medical center from June through December 2021 during a SARS-CoV-2 delta variant wave. Breakthrough occurred mostly beyond 150 days after two-dose vaccination with a mean of 239 days. Anti-SARS-CoV-2 spike (S) IgG levels were low at 0 to 2 days postsymptoms but increased in subjects presenting thereafter. Population measurements of anti-S IgG and angiotensin converting enzyme-2 receptor (ACE2-R) binding inhibition among uninfected, vaccinated patients suggested immune decay occurred after 150 days with 62% having anti-S IgG levels at or below 1,000 AU comparable with breakthrough patients at 0 to 2 days postsymptom onset. In contrast, vaccination after resolved infection conferred robust enduring anti-S IgG levels (5,000 to >50,000 AU) with >90% ACE2-R binding inhibition. However, monoclonal antibody (MAb)-treated patients did not benefit from their prior infection suggesting impaired establishment of B cell memory. Analysis of boosted patients confirmed the benefit of a third vaccine dose with most having anti-S IgG levels above 5,000 AU with >90% ACE2-R binding inhibition, but a subset had levels <5,000 AU. Anti-S IgG levels >5,000 AU were associated with >90% ACE2-R binding inhibition and no documented breakthrough infections, whereas levels falling below 5,000 AU and approaching 1,000 AU were associated with breakthrough infections. Thus, quantitative antibody measurements may provide a means to guide vaccination intervals for the individual. IMPORTANCE Currently, clinicians have no guidance for the serologic assessment of SARS-Cov-2 postvaccination status regarding protection and risk of infection. Vaccination and boosters are administered blindly without evaluation of need or outcome at the individual level. The recent development of automated quantitative assays for anti-SARS-CoV-2 spike protein IgG antibodies permits accurate measurement of humoral immunity in standardized units. Clinical studies, such as reported here, will help establish protective antibody levels allowing identification and targeted management of poor vaccine responders and vaccinated subjects undergoing immune decay.

Best Practices for Education and Training of Resuscitation Teams for In-Hospital Cardiac Arrest.

BACKGROUND: Survival outcomes following in-hospital cardiac arrest vary significantly across hospitals. Research suggests clinician education and training may play a role. We sought to identify best practices related to the education and training of resuscitation teams. METHODS: We conducted a descriptive qualitative analysis of semistructured interview data obtained from in-depth site visits conducted from 2016 to 2017 at 9 diverse hospitals within the American Heart Association "Get With The Guidelines" registry, selected based on in-hospital cardiac arrest survival performance (5 top-, 1 middle-, 3 low-performing). We assessed coded data related to education and training including systems learning, informal feedback and debrief, and formal learning through advanced cardiopulmonary life support and mock codes. Thematic analysis was used to identify best practices. RESULTS: In total, 129 interviews were conducted with a variety of hospital staff including nurses, chaplains, security guards, respiratory therapists, physicians, pharmacists, and administrators, yielding 78 hours and 29 minutes of interview time. Four themes related to training and education were identified: engagement, clear communication, consistency, and responsive leadership. Top-performing hospitals encouraged employee engagement with creative marketing of new programs and prioritizing hands-on learning over passive didactics. Clear communication was accomplished with debriefing, structured institutional review, and continual, frequent education for departments. Consistency was a cornerstone to culture change and was achieved with uniform policies for simulation practice as well as reinforced, routine practice (weekly, monthly, quarterly). Finally, top-performing hospitals had responsive leadership teams across multiple disciplines (nursing, respiratory therapy, pharmacy and medicine), who listened and adapted programs to fit the needs of their staff. CONCLUSIONS: Among top-performing hospitals excelling in in-hospital cardiac arrest survival, we identified core elements for education and training of resuscitation teams. Developing tools to expand these areas for hospitals may improve in-hospital cardiac arrest outcomes.

Seroprevalence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection among Veterans Affairs healthcare system employees suggests higher risk of infection when exposed to SARS-CoV-2 outside the work environment.

OBJECTIVE: The seroprevalence of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) IgG antibody was evaluated among employees of a Veterans Affairs healthcare system to assess potential risk factors for transmission and infection. METHODS: All employees were invited to participate in a questionnaire and serological survey to detect antibodies to SARS-CoV-2 as part of a facility-wide quality improvement and infection prevention initiative regardless of clinical or nonclinical duties. The initiative was conducted from June 8 to July 8, 2020. RESULTS: Of the 2,900 employees, 51% participated in the study, revealing a positive SARS-CoV-2 seroprevalence of 4.9% (72 of 1,476; 95% CI, 3.8%-6.1%). There were no statistically significant differences in the presence of antibody based on gender, age, frontline worker status, job title, performance of aerosol-generating procedures, or exposure to known patients with coronavirus infectious disease 2019 (COVID-19) within the hospital. Employees who reported exposure to a known COVID-19 case outside work had a significantly higher seroprevalence at 14.8% (23 of 155) compared to those who did not 3.7% (48 of 1,296; OR, 4.53; 95% CI, 2.67-7.68; P < .0001). Notably, 29% of seropositive employees reported no history of symptoms for SARS-CoV-2 infection. CONCLUSIONS: The seroprevalence of SARS-CoV-2 among employees was not significantly different among those who provided direct patient care and those who did not, suggesting that facility-wide infection control measures were effective. Employees who reported direct personal contact with COVID-19-positive persons outside work were more likely to have SARS-CoV-2 antibodies. Employee exposure to SARS-CoV-2 outside work may introduce infection into hospitals.

Cardiac tamponade after superior vena cava stenting.

Superior vena cava (SVC) syndrome results from the blockage of venous blood flow through the SVC, which is caused by either internal obstruction (eg, thrombus) or external compression (eg, thoracic malignancy and infection).1 While thrombus-related SVC syndrome is rising in prevalence, malignancy still accounts for the majority of cases.1 Regardless of cause, SVC syndrome is characterised by facial swelling and plethora, headache and dyspnoea.2 Although venous stenting has become standard of care for treatment of acute SVC syndrome, stent placement presents multiple risks including SVC rupture and cardiac tamponade. In these cases, a high index of suspicion and prompt action are required to avoid an often fatal outcome. Here, we present the case of a patient with cardiac tamponade and subsequent cardiac arrest after SVC stent placement.

How often are health care personnel hands colonized with multidrug- resistant organisms? A systematic review and meta-analysis.

BACKGROUND: Hands of health care personnel (HCP) can transmit multidrug-resistant organisms (MDROs), resulting in infections. Our aim was to determine MDRO prevalence on HCP hands in adult acute care and nursing facility settings. METHODS: A systematic search of PubMed/MEDLINE, Web of Science, CINAHL, Embase, and Cochrane CENTRAL was performed. Studies were included if they reported microbiologic culture results following HCP hands sampling; included prevalent MDROs, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, Clostridium difficile, Acinetobacter baumannii, or Pseudomonas aeruginosa, and were conducted in acute care or nursing facility settings. RESULTS: Fifty-nine articles comprising 6,840 hand cultures were included. Pooled prevalence for MRSA, P aeruginosa, A baumannii, and vancomycin-resistant Enterococcus were 4.26%, 4.59%, 6.18%, and 9.03%, respectively. Substantial heterogeneity in rates of pathogen isolation were observed across studies (I2 = 81%-95%). Only 4 of 59 studies sampled for C difficile, with 2 of 4 finding no growth. Subgroup analysis of MRSA revealed the highest HCP hand contamination rates in North America (8.28%). Sample collection methods used were comparable for MRSA isolation (4%-7%) except for agar direct contact (1.55%). CONCLUSIONS: Prevalence of common MDROs on HCP hands vary by pathogen, care setting, culture acquisition method, study design, and geography. When obtained at an institutional level, these prevalence data can be utilized to enhance knowledge, practice, and research to prevent health care-associated infections.

Safe and Effective Bedside Thoracentesis: A Review of the Evidence for Practicing Clinicians.

BACKGROUND: Physicians often care for patients with pleural effusion, a condition that requires thoracentesis for evaluation and treatment. We aim to identify the most recent advances related to safe and effective performance of thoracentesis. METHODS: We performed a narrative review with a systematic search of the literature. Two authors independently reviewed search results and selected studies based on relevance to thoracentesis; disagreements were resolved by consensus. Articles were categorized as those related to the pre-, intra- and postprocedural aspects of thoracentesis. RESULTS: Sixty relevant studies were identified and included. Pre-procedural topics included methods for physician training and maintenance of skills, such as simulation with direct observation. Additionally, pre-procedural topics included the finding that moderate coagulopathies (international normalized ratio less than 3 or a platelet count greater than 25,000/µL) and mechanical ventilation did not increase risk of postprocedural complications. Intraprocedurally, ultrasound use was associated with lower risk of pneumothorax, while pleural manometry can identify a nonexpanding lung and may help reduce risk of re-expansion pulmonary edema. Postprocedurally, studies indicate that routine chest X-ray is unwarranted, because bedside ultrasound can identify pneumothorax. CONCLUSIONS: While the performance of thoracentesis is not without risk, clinicians can incorporate recent advances into practice to mitigate patient harm and improve effectiveness. Journal of Hospital Medicine 2017;12:266-276.

A Case of Right Atrial Obliteration Caused by Intracardiac Extension of Hepatocellular Carcinoma.

As the fifth most common malignancy worldwide, hepatocellular carcinoma (HCC) is a frequently encountered clinical entity. Symptomatology associated with the diagnosis includes hepatic dysfunction and pain from capsular spread. Additionally, due to its propensity for vascular spread, extrahepatic intravascular involvement can also be seen. We present a unique case of intracardiac involvement of HCC. Originally diagnosed as acute on chronic heart failure, echocardiography revealed the symptom source - tumor obliteration of the right atrium. Clinical case presentation and management, along with radiographic images are presented. A review of the current literature highlights this uncommon presentation and the need for clinical suspicion of cardiac involvement in patients with a history of HCC presenting with heart failure.