SCI Quality Enhancement Research Initiative
(QUERI): Building and Implementing Evidence
OFFICE of RESEARCH & DEVELOPMENT
Authors: Charlesnika T. Evans, PhD, MPH; Marylou Guihan, PhD; Sherri L. LaVela, PhD, MPH, MBA; Frances M. Weaver, PhD; Barry Goldstein, MD, PhD; Bridget Smith, PhD
Charlesnika T. Evans, PhD, MPH Marylou Guihan, PhD PVA SUMMIT 2014
Disclaimer
The views expressed in this presentation are the
presenters and do not necessarily reflect the position or
policy of the Department of Veterans Affairs or the US
government.
Overview
•
Background on QUERI and implementation research
•
Overview of SCI QUERI mission and goals
•
Brief review of Function and Virtual Health goals
•
Detailed over of Infection Prevention and
Management and Pressure Ulcers goals
What is QUERI?
•
VA Quality Enhancement Research Initiative (QUERI)
• SCI QUERI is one of 10 QUERI programs
•
Launched in 1998 as part of a system-wide
transformation aimed at improving the quality of
healthcare for Veterans
•
QUERI contributes to this effort by implementing
research findings and innovations into routine
clinical practice
Six-Step QUERI Process
1. Identify high risk/high burden conditions
2. Identify best practices (i.e. strong evidence, clinical guidelines) 3. Define existing practice patterns and variations from best practice
(current practices, quality gaps)
4. Identify or develop and implement programs to promote best practices
5. Evaluate improvement program feasibility, implementation, and impacts on patient, family, and healthcare system processes and outcomes
What is Implementation Research?
•
The scientific study of methods to promote the
systematic uptake of research findings and other
evidence-based practices into routine practice
•
Includes the study of influences on healthcare
professional and organizational behavior
•
Goal is to improve the quality and effectiveness of
health services
To promote health, independence,
functioning, quality of life, and productivity of
Veterans with spinal cord injuries and
disorders (SCI/D), through the
implementation of evidence-based findings.
SCI QUERI Priority Areas
•
Virtual Health
•
Optimization of Function
•
Infection Prevention and Management
VETERANS HEALTH ADMINISTRATION 10
What is Virtual Health?
• Technologies such as telehealth or personal health records
• Clinical video telehealth
– SCI Center to spoke
– SCI Center or spoke to home
• MyHealtheVet is VA’s personal health portal offering:
– Secure messaging
– Health education information
– Prescription refills
– Appointment views
Where Are We Going?
Virtual Health
• Enhance implementation of clinical video telehealth to
increase access to care (especially specialty care) for Veterans with SCI/D
• Enhance implementation of secure messaging and use
• Integrating virtual health to improve discharge planning
• Anticipated Key Impacts
• Decrease travel time and costs for Veterans
• Increase Veteran engagement
• Increase information exchange between providers
• Develop and disseminate toolkits to assist with implementation
Function
•
Mobility
•
Activities
Where are we going?
Function
•
Assistive technology
• Evaluating implementation of environmental control units
(ECUs)
•
Participation
•
Persons with SCI/D have frequent infections due to
many factors such as chronic use of invasive devices
(i.e., urinary catheterization) or repeated
hospitalizations
•
Identification of true infection can be complex (i.e.,
Urinary catheters add complexity to diagnosis of UTI because of colonization of catheters with microorganisms)
•
Many of these infections are caused by
microorganisms that are resistant to first-line or
common treatments
Infection Goal
Prevent and improve management of
infections and healthcare outcomes.
•
Current areas of focus include:
•
Improving healthcare worker influenza vaccinations
•
Prevention and management of drug-resistant
organisms and
Clostridium Difficile
Infection (CDI)
•
Improving antimicrobial prescribing
•
Improved patient vaccination rates
• Influenza vaccination rates from 28% in 2000 to 79% in 2010
• Pneumococcal pneumonia vaccination rates from 40% in
2000 to 94% in 2010
• Identified low vaccination rates in healthcare workers (HCWs) in
SCI centers (48%; VA average 77% for all HCWs)
• Low HCW vaccination rates continue
LaVela SL et al, 2004; 25(11): 933-940; LaVela SL et al, 2007;35(7): 448-454.
Where have we been?
Influenza Prevention
Where are we going?
Improving HCW vaccination
• Declination form programs - Formal statements of declining
influenza vaccination
• Declination forms have been used on their own or as an
‘opt-out’ component of a mandatory vaccination campaign
• Reported as one of the most effective techniques for
increasing HCW influenza vaccination rates and have increased HCW vaccination rates up to 22% in general HCW populations
• Over 50% of SCI/D HCWs would be influenced by a declination
form program as a strategy to improve HCW influenza vaccination (n=365)
Where are we going?
Improving HCW vaccination
• Pilot a Declination Form Program at 2 SCI Centers to improve
influenza vaccination in HCWs (PI: LaVela – RRP ongoing) • Implementation process of a declination form program
• Outcomes: Impacts on HCW vaccinations and costs of implementation
•
Current areas of focus include:
•
Improving healthcare worker influenza vaccinations
•
Prevention and management of drug-resistant
organisms and
Clostridium Difficile
Infection (CDI)
•
Improving antimicrobial prescribing
• Developed SCI/D-specific patient education toolkit related to the VA MRSA program
• Designed to be interactive between
healthcare provider and the patient
• Brochure, flip chart, patient aptitude test, return
demonstration of skill for hand hygiene, SCI/D MRSA care
guidelines, toolkit instructions
Hill J et al. JSCM 2013; Evans et al. JSCM, 2013
Where have we been?
MRSA Prevention & Management
Where have we been?
MRSA Prevention & Management
• Need to understand current practice and implementation of
MRSA guidelines in VA SCI Centers
• Collaborated with VA patient care offices highlighting VA SCI
Centers’ experience using their data and SCI QUERI survey data
• Highlights:
• Average prevalence of MRSA in SCI/D centers is 38.6% (range 19.2%-54.6%)
• VA MRSA Initiative has helped reduce MRSA hospital-acquired infections in SCI/D patients
• Identified need for SCI/D specific patient education materials
Where have we been?
MRSA Prevention & Management
• Highlights continued:
• Identified need for additional training of providers in educating patients
• Barriers to implementing contact precautions
• Environmental cleaning practices unclear
• Facilitators to implementation: Leadership support and perceptions of strength of evidence for MRSA prevention practices strong
Where are we going?
Focus on other initiatives
• Prevention of Clostridium difficile
infection (CDI) in VHA (July 2012)
• Evaluate implementation of CDI bundle in VA SCI/D Units
• Impacts: Identify barriers and
facilitators to implementation of the CDI bundle with a focus on
environmental cleaning
• Work with VA patient care service
partners early on to evaluate implementation needs
•
Current areas of focus include:
•
Improving healthcare worker influenza vaccinations
•
Prevention and management of drug-resistant
organisms and
Clostridium Difficile
Infection (CDI)
•
Improving antimicrobial prescribing
•
High use of antibiotics in SCI/D as a result of frequent
infections
•
Providing adequate and appropriate empiric treatment is
challenging
•
Impacts of antimicrobial prescribing on patient outcomes
• Increased multidrug resistance – it’s a cycle
• Increased morbidity and mortality
• Development of C. difficile infection
• Adverse drug reactions
Evans CT et al. J Spinal Cord Med, 2013;36:492-498; Evans CT et al. Arch Phys Med Rehabil, 2009;90:1364-1370.
Background
Where are we going?
Antimicrobial prescribing
• Improving adequacy of antibiotic treatment (bug/drug match)
• Improving empiric antibiotic choice
• Implement use of SCI-unit specific antibiograms to help with empiric choices
• Checking culture results to determine if antibiotic treatment needs to be changed
• Reduce treatment of colonization rather than infection
• UTI vs asymptomatic bacteriuria (colonization)
• Develop SCI/D-specific toolkits (patient/provider) to promote
Summary
• Infection Prevention and Management is an important area
for implementation research for SCI QUERI
• Improving influenza vaccinations in HCWs
• Addressing infections caused by MDROs and C. difficile
• Improving antimicrobial prescribing and management of these infections
Background PrUs in SCI
• People with SCI are at high risk for PrUs throughout their
lifetimes due to decreased mobility, lack of sensation and other physiologic changes.
• PrUs are among the most frequent and significant complications
after SCI.
• Veterans with SCI and a new PrU had more total inpatient days
on average (61.0 vs. 9.2; P<0.001) and higher total healthcare costs ($100,935 vs. $27,914; P<0.001) than those without PrUs, primarily due to higher inpatient costs ($91,341 vs. $13,754; P<0.05).
• These costs do not reflect whether the ulcer was ultimately
Background PrUs in SCI
• PrU prevalence rates in SCI are high: 25% during acute
rehabilitation and 36% in the community.
• Recurrence rates are also high, our studies have documented
that:
• Recurrence rates after a healed ulcer among those living in the
community were high, 40% within 4 months post-discharge.
• In most recent study, 52% experienced a recurrence, usually
within 3 months post-discharge, most frequently within 30 days post-discharge.
Where do Veterans with SCI get PrUs?
•
Of the PrUs treated in VA SCI units, only 1.3% were
hospital-acquired.
•
Community-acquired PrUs are one of the main reasons
for hospitalization of Veterans with SCI/D.
HAPUs
Pressure Ulcer (PrU)
Strategic Planning Process
•
PrU workgroup (SCI clinicians and researchers)
•
SCI-PrU Monitoring Tool (SCI-PUMT) Clinical
Champions
•
Input from SCI chiefs
Building the Base
Pressure Ulcer Workgroup
• A limited number of investigators are working in the area of PrUs in
SCI/D.
• In 2012, we formally organized a PrU workgroup consisting of
researchers, SCI providers, nurses, researchers, and surgeons.
• Our PrU Workgroup provides a growing base of persons involved
with our PrU initiatives.
• Our monthly meeting sets the agenda and plans projects to
address PrU prevention and treatment and identify opportunities for collaboration.
Overall
PrU Goals
1. Evaluate implementation of SCI-PUMT.
2. Test and implement a SCI-specific community
PrU risk assessment (PURT) (HSR&D).
3. Implement a checklist to improve receipt of PrU
prevention CPGs.
4. Use SCI-PUMT data to evaluate PrU treatment.
5. Develop clinical decision support tools for PrU
SCI-PUMT Goals
1. Incorporate SCI-PUMT into electronic data capture into other ongoing VA initiatives
2. Increase SCI-PUMT use by SCI/D providers by building long term sustainability in high-adopting SCI/D Centers
3. Increase SCI-PUMT implementation/uptake at medium-adopting SCI centers using best practices from high adopting sites
4. Increase SCI-PUMT use across settings (outpatient, home care, spoke sites) at high/medium adopting sites
5. Develop new implementation strategies to increase SCI-PUMT use at low-adopting SCI/D centers
Evaluating Implementation of
SCI-PUMT (PrU Monitoring Tool)
Standardize PrU assessment, eventually treatment?
•
SCI-PUMT implementation will improve standardization
of PrU assessment and monitoring.
•
It will improve our ability to conduct comparative
effectiveness studies on PrU interventions.
• Conducted site visits to evaluate SCI-PUMT implementation at 7 SCI Centers.
• Obtained needed data on variability of implementation process to inform development of interventions to improve uptake.
• We identified which SCI/D Center sites may be better able to involve their spoke sites in using the SCI-PUMT.
Variables Scoring Options Score GEOMETRIC FACTORS Surface Area (L x W) 1 > 0 - ≤1 cm2 2 >1 - ≤2.5 cm2 3 >2.5 - ≤5 cm2 4 >5 - ≤10 cm2 5 >10 - ≤15 cm2 6 >15 - ≤25 cm2 7 >25 - ≤35 cm2 8 >35 - ≤55 cm2 9 >55 - ≤85 cm2 10 >85 cm2 L x W __ cm x __cm
Do not continue if the Surface Area is “O” indicating complete epithelialization (i.e., resurfacing)
Depth 0 0 cm 1 >0 - ≤1 cm 2 >1 - ≤2 cm 3 >2 - ≤3 cm 4 >3 cm D ___ cm
Edges Not rolled under, thickened, fibrotic, scarred, 1
or hyperkeratotic
2
Rolled under, thickened, fibrotic, scarred, or hyperkeratotic Tunneling 0 None 1 ≤ 2 cm 2 > 2 - ≤ 4 cm 3 >4 cm Undermining 0 None 1 ≤ 2 cm 2 > 2 - ≤ 4 cm 3 >4 cm GEOMETRIC SUBTOTAL SUBSTANCE FACTORS Exudate Type None 0 1 Serous or Sanguineous 2 Green or Purulent Necrotic Tissue Amount 0 None 1 ≤ 25% 2 >25% SUBSTANCE SUBTOTAL TOTAL
Pressure Ulcer Data Needs
•
Currently available VA data do not include: number, severity,
location, recurrence and/or history of previous ulcers. This
remains a significant issue for SCI QUERI.
•
Although VA SCIDO and VANOD databases hold great
promise, neither is advanced enough to address QUERI’s data
needs for PrUs in the near future.
•
Current and planned studies will continue to collect primary
data.
What we know so far about
implementation of the SCI-PUMT
• Uneven implementation across 23 SCI/D Centers as of Sept. 2012, with only50% of sites reporting completing SCI-PUMT training of all relevant nursing staff.
• Low-adopting sites indicated that they had used fewer of the SCI-PUMT Toolkit items.
• We have identified some common characteristics among high-adopting sites, e.g., while all have established interprofessional wound care teams, these teams differ considerably in composition and care processes.
• High adopting SCI Centers have created local work-arounds to enable use of the SCI-PUMT.
• By far, the biggest obstacle to SCI-PUMT use is the lack of a centralized area for documentation of SCI-PUMT data.
Anticipated Key Impacts
•
Learning more about implementation across 24
SCI/D Centers for future studies.
•
Building a PrU database using SCI-PUMT data to
use for future inquiries.
•
Broadening our network of PrU researchers to
increase our reach (VA Office of Nursing Services,
Diabetes QUERI, PrU workgroup).
PrU Summary
•
Some PrU risk factors are unique to SCI.
•
SCI providers report that existing risk assessment
and wound healing tools have to address the
unique factors in SCI/D.
•
Risks and consequences of PrU are much higher
Summary
• Persons with SCI/D experience issues unique to SCI as well as
conditions common to all (e.g., infection)
• Risks and consequences are often higher in SCI/D
• Efforts to improve the health and outcomes of persons with
SCI/D requires
• Implementing evidence
• Standardizing measurement
• Identifying and addressing barriers
• Addressing gaps in care delivery
Opportunities to collaborate with QUERI
•
We have reached out to investigators addressing
ideas relevant to our focus areas
•
But don’t wait for us to call you. Various
opportunities exist. You can participate as:
•
A site in multi-site study
•
A content expert
•
An investigator on an SCI QUERI study
SCI QUERI Contact Information
Research Coordinating Center Co-Directors:Charlesnika T. Evans, PhD, MPH charlesnika.evans@va.gov
Bridget Smith, PhD bridget.smith@va.gov
Assistant Director
Marylou Guihan, PhD marylou.guihan@va.gov
Clinical Coordinator:
Barry Goldstein, MD barry.goldstein@va.gov
Implementation Research Coordinators:
Henry Anaya, PhD henry.anaya@va.gov
Jennifer Hill, MA jennifer.hill3@va.gov
Administrative Coordinator:
Dolores Ippolito, MPH dolores.ippolito2@va.gov
SCI QUERI Investigators & Affiliates
Barbara Bates-Jensen, PhD, RN, FAAN
Charlesnika T. Evans, PhD, MPH
Ben Gerber, MD, MPH
Barry Goldstein, MD, PhD
Marylou Guihan, PhD
Sherri LaVela, PhD, MPH, MBA
Sara Locatelli, PhD
Rachael Martinez, PhD
Suparna Rajan, PhD
Nasia Safdar, MD
Katie Suda, PharmD
Bridget Smith, PhD
Frances Weaver, PhD
SCI QUERI Executive Committee
Leigh Anderson, MD
Barbara Bates-Jensen, PhD, RN, FAAN
Stephen Burns, MD
Charlesnika T. Evans, PhD, MPH
Martin Evans, MD
Barry Goldstein, MD, PhD
Gail Powell-Cope, PhD, ARNP, FAAN
Sunil Sabharwal, MD
Arthur Sherwood, PhD, PE
Bridget Smith, PhD
Carol VanDeusen Lukas, EdD
Frances Weaver, PhD
