SCI Quality Enhancement Research Initiative (QUERI): Building and Implementing Evidence







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SCI Quality Enhancement Research Initiative

(QUERI): Building and Implementing Evidence


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



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




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



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






Where are we going?


Assistive technology

• Evaluating implementation of environmental control units




Persons with SCI/D have frequent infections due to

many factors such as chronic use of invasive devices

(i.e., urinary catheterization) or repeated


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


Providing adequate and appropriate empiric treatment is


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.



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



• 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


• 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


Community-acquired PrUs are one of the main reasons

for hospitalization of Veterans with SCI/D.



Pressure Ulcer (PrU)

Strategic Planning Process

PrU workgroup (SCI clinicians and researchers)

SCI-PrU Monitoring Tool (SCI-PUMT) Clinical


Input from SCI chiefs


Building the Base

Pressure Ulcer Workgroup

• A limited number of investigators are working in the area of PrUs in


• 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.



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



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


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



What we know so far about

implementation of the SCI-PUMT

• Uneven implementation across 23 SCI/D Centers as of Sept. 2012, with only

50% 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



• 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

Bridget Smith, PhD

Assistant Director

Marylou Guihan, PhD

Clinical Coordinator:

Barry Goldstein, MD

Implementation Research Coordinators:

Henry Anaya, PhD

Jennifer Hill, MA

Administrative Coordinator:

Dolores Ippolito, MPH


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

SCI QUERI Investigators and



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