Emergency Departments Treating Veterans for Suicide: Ensuring Quality Care for Veterans Outside of Department of Veterans Affairs Health Care Facilities

IntroductionVeterans die by suicide at higher rates than nonveterans. Given that the emergency department is often the first point of entry to healthcare following a suicide attempt, it would be beneficial for community providers to have knowledge of the characteristics, medical issues, and effective treatments most often associated with those having served in the military to ensure guideline concordant and quality suicide care. This study aimed to identify assessment and referral practices of emergency departments at rural community hospitals related to care for suicidal veterans and explore the feasibility and acceptability of identifying veterans in need of postdischarge aftercare.MethodsThis qualitative exploratory study involved content analysis of semistructured interviews. Ten emergency clinicians from 5 rural Arkansas counties with high suicide rates were interviewed about their experiences working with suicidal patients within the emergency department and perceptions of assessment, management, and referral practices.ResultsAlthough most of the emergency departments had a process for assessing for suicide risk, emergency clinicians did not always feel confident in their knowledge of assessing and caring for suicidal patients. Military history was not included in assessment, treatment, or aftercare planning, nor were brief interventions such as safety planning or lethal means safety education provided.DiscussionBest practices for suicide assessment and management of veterans exist; however, challenges specific to the emergency department regarding staff training and engaging the community to effectively link at-risk veterans to needed care hinder implementation. Veteran-inclusive assessment and intervention practices could enhance the quality of care provided in community emergency departments.     

美国退伍军人事务部/国防部成人脑卒中康复治疗管理临床实践指南(执行简写版)

背景专家委员会制定的卒中康复指南应用于退伍军人健康管理部门及国防部卫生保健系统。方法根据以前发表的指南，委员会利用美国预防服务特别工作组制定的标准。评价了截至到2002年发表的文献。指南根据临床随机化实验、非对照性研究等证据提出建议（如缺乏确定的数据则根据专家组的建议）。结果 Ⅰ级水平的建议包括：在多学科康复环境中或卒中单元中传递卒中治疗，通过NIHSS对卒中患者进行评价，早期启动康复治疗，对吞咽困难患者进行吞咽功能筛查，积极进行二级预防，预防深静脉血栓等。推荐应用标准化的评价上具制定适合每个患者的全面的治疗计划。强烈建议进行抗抑郁及情感波动方面的治疗。语言治疗师应评价患者的交流及认知障碍。并在需要时提供治疗。患者、家属及护理者是康复小组的重要成员，应当介入康复的全部疗程。这些建议在以下网站可查询：http：／／stroke．ahajournals．org／cgi／content／full／36／9／e100。并附有每项建议的全文证据表。结论这些建议应平等地应用于所有临床环境中的所有卒中康复患者，而不是仅针对联邦医疗系统的临床问题或资源。     

Use of the electronic record in the home-based primary care programs of the Department of Veterans Affairs Health Care System

Use of the electronic record in the Home-Based Primary Care (HBPC) programs of the Department of Veterans Affairs (VA) Health Care System is described. The VA electronic record is a complete computerized system for a patient's record. The use of this system provides instant information on the health status of each patient referred to and managed by home care.     

Reducing Nonemergent Visits to the Emergency Department in a Veterans Affairs Multistate System

Study ObjectiveThe purpose of this quality improvement study was to reduce nonemergent visits to the emergency department attendance within a multistate Veterans Health Affairs network.MethodsTelephone triage protocols were developed and implemented for registered nurse staff to triage selected calls to a same-day telephonic or video virtual visit with a provider (physician or nurse practitioner). Calls, registered nurse triage dispositions, and provider visit dispositions were tracked for 3 months.ResultsThere were 1606 calls referred by registered nurses for provider visits. Of these, 192 were initially triaged as emergency department dispositions. Of these, 57.3% of calls that would have been referred to the emergency department were resolved via the virtual visit. Thirty-eight percent fewer calls were referred to the emergency department following licensed independent provider visit compared to the registered nurse triage.ConclusionTelephone triage services augmented by virtual provider visits may reduce emergency department disposition rates, resulting in fewer nonemergent patient presentations to the emergency department and reducing unnecessary emergency department overcrowding. Reducing nonemergent attendance to emergency departments can improve outcomes for patients with emergent dispositions.     

Evaluation of Care in Psychogeriatric Units: Family Support in Quality of Care

ABSTRACT As institutionalised psychogeriatric patients are very vulnerable, a pilot project was undertaken to develop an instrument to evaluate the quality of their care. The proposed instrument is based on qualitative findings from observations, interviews, records and literature review. It focuses on individual patients, groups of patients, families and the unit, and includes nine items which are measured in terms of administrative, affective and instrumental aspects of care. This paper only describes the data gathered on one of these foci—the involvement of families as both providers of care and as clients requiring support. From the data it appears that the family role as a provider of care is enhanced by support received from the staff and, therefore, family support was selected as an item by which to evaluate quality of care. Material from the data was used as examples for assigning quantitative values to aspects of family involvement.     

Persistence with hepatitis C therapy in the Department of Veterans Affairs

Background: Persistence with Hepatitis C therapy has been identified as a key variable for predicting treatment success. The primary purpose of this study was to assess the persistence with therapy for patients undergoing hepatitis C treatment in the VA healthcare system with two forms of combination therapies: peginterferon alfa‐2a with Ribavirin (peg‐IFN alpha‐2a/Rib) and peginterferon alpha‐2b with Ribavirin (peg‐IFN alpha‐2b/Rib). Methods: A retrospective cohort study design was used to analyse persistence in VA patients undergoing hepatitis C therapy during FY 2003–2004 using a large national VA data set. Stringent inclusion and exclusion criteria along with various defining variables were used to identify the inception cohort. Persistence rates were calculated for each of the two treatment groups at 3, 6, 9 and 11 months using the Kaplan–Meier method. Likelihood ratio test of equality between the two treatment groups was performed to detect any differences in persistence rates. Results: A total of 5816 hepatitis C patients formed the inception cohort. Persistence rates for the overall duration showed significantly higher rates for patients on peg‐IFN alpha‐2a/Rib than peg‐IFN alpha‐2b/Rib. Cox regression analysis also showed favourable hazard ratio of persistence (0·88) for peg‐IFN alpha‐2a/Rib over peg‐IFN alpha‐2b/Rib. Conclusion: Peg alfa‐2A/Rib showed slightly higher persistence rates for the overall duration of treatment as compared to Peg alfa‐2B/Rib. However the differences, even though statistically significant, are small and not likely to translate into any substantial clinical advantage. Further research involving other approaches is required to confirm these findings.     

Historical perspective on the development of outcomes measures for low-vision and blind rehabilitation in the Department of Veterans Affairs

This article reviews the instrument development process and synthesizes current research findings for three low-vision and blind rehabilitation outcomes measures developed in the Department of Veterans Affairs (VA). The examined measures include the Blind Rehabilitation Service Functional Outcomes Survey, the Functional Assessment of Self-Reliance on Tasks, and the VA Low Vision Visual Functioning Questionnaire. We examined vision rehabilitation literature using two fundamental measurement criteria to compare and contrast the instrument development process and research findings for the three measures. Our findings suggest the three measures need refinement to meet the two criteria and proposed measurement standards for instruments in this field. Advanced development goals for the instruments are identified. Measures that meet the specified and proposed measurement criteria will help establish an evidence-based system and guide practice at the VA and in the field.     

Belgian General Practitioners' Perspectives on the Use of Palliative Sedation in End-of-Life Home Care: A Qualitative Study

ContextPalliative sedation (PS) is a far-reaching palliative measure with a life-shortening potential. Guidelines provide only for a restricted use of PS and as a last resort.ObjectivesTo explore PS practice in end-of-life (EoL) home care.MethodsThis was a qualitative analysis of semi-structured interviews with 52 general practitioners (GPs) of Flanders, Belgium.ResultsApart from GPs who adhere to the existing prerequisites for PS, opinions diverge among GPs on the indication area for PS and on possible life-shortening intentions. The key to GPs' broadened view on “which suffering merits PS” is the fragile context of EoL home care, and the key to GPs' possible life-shortening intentions is their need to facilitate the dying process, when trying or lengthy. When honoring a terminally ill patient's request for euthanasia, several GPs prefer slow euthanasia using PS to a lethal injection.ConclusionPS home practice deviates from the PS guidelines' recommendations. In addition to the GPs' shortage of knowledge, the guidelines' recommendations do not always meet the particular needs of EoL home care. If one consideration of EoL home care is to respect a patient's wish to die at home, then the pre-emptive use of PS to avoid a futile transfer to the hospital in the case of an undesirable turn of events deserves more attention in the PS debate.     

Important Attributes of Quality Health Care: Consumer Perspectives

Purpose: Despite extensive research on defining and measuring health care quality, little attention has been given to consumers' perspectives of high-quality health care. The purposes of this study were to (a) identify the importance to consumers of attributes of health care quality and nursing care quality, and (b) examine the relationship of consumer perspectives to health status and selected demographic variables.
Design: Exploratory. Consumers (N = 239) were recruited from waiting rooms of clinics and in neighborhoods of a large metropolitan area in the Midwestern United States that included both urban and suburban populations.
Methods: Participants completed the Quality Health Care Questionnaire (QHCQ) and the SF-36 Health Survey. On the QHCQ, they rated the importance of 27 attributes of health care and nursing care quality. The SF-36 is a 36-item instrument for measuring health status in eight general areas.
Findings: The most important indicators of high-quality nursing care to consumers were: being cared for by nurses who are up-to-date and well informed; being able to communicate with the nurse; spending enough time with the nurse and not feeling rushed during the visit; having a nurse teach about the illness, medications, treatments, and staying healthy; and being able to call a nurse with questions. The lowest-rated item was having an opportunity to be cared for by nurse practitioners. Ratings differed by race, age, years of education, income, and health status.
Conclusions: The importance that consumers place on teaching by the nurse was emphasized, particularly among people with less education, low income levels, and chronic illnesses.     

Emergency Department Utilization by the Elderly: Analysis of the National Hospital Ambulatory Medical Care Survey

Objective : To characterize the ED utilization patterns of the elderly population using nationally representative data.
Methods : A secondary analysis was performed using the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationwide, stratified probability sample of ED encounters. Using these physician-reported data, the demographics, patient complaints, physician diagnoses, and dispositions were compared by age group, i.e., young-old (age 65–84 years) vs old-old (age ±85 years).
Results : The elderly (age ±65 years) represented 5,038 (19.6%) of 25,646 ED encounters for all adults (age ±18 years). The geriatric age groups (ages 65–74, 75–84, and ±85 years) accounted for 45.3%, 37.4%, and 17.2% of all the encounters by the elderly. The proportions of female patients and white patients were higher with increasing age. The proportion of elderly patients hospitalized was 4 times that of younger adults and reflected monotonic increase with increasing age among elders. Patient complaints and physician diagnoses were generally similar for the young-old (65–84 years) and the old-old (±85 years).
Conclusions : These findings are consistent with previous single-center studies of geriatric ED patients. This data source may be useful for investigation of clinical issues related to the care of elderly ED patients.     

Evaluation of Veterans Affairs primary care nurse practitioner residency: Achievement of competencies

Background

The Institute of Medicine has recommended the establishment of residency programs for advanced practice nursing graduates. Currently, the evidence about program effectiveness is limited.

康复临床实践指南:方法学质量研究

目的 评价康复临床实践指南的方法学质量。方法 检索PubMed、EMBASE、万方数据库、中国知网(CNKI)和中国生物医学文献数据库(CBM)及医脉通、英国国家卫生与临床优化研究所(NICE)、美国国立指南文库(NGC)、苏格兰校际指南协作网(SIGN)、世界卫生组织(WHO)、国际指南协作网(GIN)网站已公开发表的与康复医学相关的临床实践指南,检索时限均为从建库至2020年1月11日。由2名研究人员独立筛选文献并交叉核对,基于指南研究与评价(AGREE) Ⅱ工具对纳入的临床实践指南的方法学质量进行评价。 结果 共纳入指南84篇,其中英文67篇,中文17篇。基于AGREE Ⅱ工具的整体评价平均得分为48.1%,其中国外指南为49.9%,国内指南为40.7%。AGREE Ⅱ 6个领域中,除应用性外,国外指南平均得分均高于国内指南(| Z| > 2.034, P < 0.05);AGREE Ⅱ发布后,表达清晰性和编辑独立性的评分均高于发布前( Z > 2.130, P < 0.05);得分由高到低依次是范围和目的(41.6%)、表达清晰性(39.9%)、参与人员(24.5%)、制订严谨性(23.2%)、编辑独立性(15.5%)和应用性(12.9%)。 结论 国内外康复临床实践指南的方法学质量有待提高。建议未来康复指南制订者严格按照AGREE Ⅱ标准规范化制订并撰写相关指南,重视指南制订过程中的内容和全面性,从而更好地提升指南的质量。