Marylou Guihan

Role of "external facilitation" in implementation of research findings: a qualitative evaluation of facilitation experiences in the Veterans Health Administration

BackgroundFacilitation has been identified in the literature as a potentially key component of successful implementation. It has not, however, either been well-defined or well-studied. Significant questions remain about the operational definition of facilitation and about the relationship of facilitation to other interventions, especially to other change agent roles when used in multi-faceted implementation projects.Researchers who are part of the Quality Enhancement Research Initiative (QUERI) are actively exploring various approaches and processes, including facilitation, to enable implementation of best practices in the Veterans Health Administration health care system – the largest integrated healthcare system in the United States. This paper describes a systematic, retrospective evaluation of implementation-related facilitation experiences within QUERI, a quality improvement program developed by the US Department of Veterans Affairs.MethodsA post-hoc evaluation was conducted through a series of semi-structured interviews to examine the concept of facilitation across several multi-site QUERI implementation studies. The interview process is based on a technique developed in the field of education, which systematically enhances learning through experience by stimulating recall and reflection regarding past complex activities. An iterative content analysis approach relative to a set of conceptually-based interview questions was used for data analysis.FindingsFindings suggest that facilitation, within an implementation study initiated by a central change agency, is a deliberate and valued process of interactive problem solving and support that occurs in the context of a recognized need for improvement and a supportive interpersonal relationship. Facilitation was described primarily as a distinct role with a number of potentially crucial behaviors and activities. Data further suggest that external facilitators were likely to use or integrate other implementation interventions, while performing this problem-solving and supportive role.Preliminary ConclusionsThis evaluation provides evidence to suggest that facilitation could be considered a distinct implementation intervention, just as audit and feedback, educational outreach, or similar methods are considered to be discrete interventions. As such, facilitation should be well-defined and explicitly evaluated for its perceived usefulness within multi-intervention implementation projects. Additionally, researchers should better define the specific contribution of facilitation to the success of implementation in different types of projects, different types of sites, and with evidence and innovations of varying levels of strength and complexity.

Characteristics of recurrent pressure ulcers in veterans with spinal cord injury.

Abstract Background/Objective: To describe characteristics of recurrent pressure ulcers (PrUs) in veterans with spinal cord injury (SCI). Design: Descriptive, cohort study. Settings and Participants: Twenty-four veterans with SCI from 6 SCI centers in the Department of Veterans Affairs. Methods: Data from a prospective study evaluating PrUs were analyzed for 24 veterans with 29 recurrent PrUs during 9 months. Additional retrospective medical record data were analyzed for 15 veterans who received inpatient treatment. Results: Participants were male, 50% non-Hispanic white, with paraplegia (63%), complete SCI (83%), a mean age of 56 years, and mean time since SCI of 21 years. Most PrUs recurred (63%, n = 15 patients) in the same location as the most recent ulcer and at the ischial tuberosities (63%). Mean time to recurrence was 16.6 weeks. PrUs were stage III (28%, n = 8) or IV (45%, n = 13) with undermining (48%), necrotic slough (50%), and minimal exudate. One third were (n = 9) larger than 16 cm2. Mean Bates-Jensen Wound Assessment Tool Score was 33.63. Inpatient medical record data (n = 15) showed 73% with documentation indicating infection treated with antibiotics (53%, n = 8 patients), osteomyelitis (47%, n = 7), and/or cellulitis (1 3%, n = 2) noted. Plastic surgery consultation was obtained for 67% with surgery as an option for 73% (1 without consultation). Scheduled repositioning was documented for 21%. Conclusions: Most PrUs were severe, located at the same anatomic site, and recurred within 4 months, suggesting that the recurrent ulcers were more likely incomplete healing of the initial PrUs. This sample of veterans with SCI provides early data on recurrent PrU characteristics.

Predictors of pressure ulcer recurrence in veterans with spinal cord injury.

Abstract Background/Objective: To predict recurrence of pressure ulcers (PrUs) in a high-risk populationofveterans with spinal cord injury (SCI). Design:Cross-sectional observational design. Participants: A convenience sample of 64 subjects from 6 Department of Veterans Affairs (VA) SCI Centers who had been admitted to the hospital for the treatment of stage III-IV pelvic PrUs and were healed at the time of discharge back to the community. Main Outcome Measures:Primary outcome measures were pelvic PrU recurrence, defined as selfreported new skin breakdown (stage II or greater) in the pelvic area (not necessarily in the same location as previous ulcer) and time to recurrence. Results:There were no differences between those with/without recurrences with regard to age, age at/level of injury, number of previous ulcers or surgery, rate of or time, to recurrence. Mean age was 56 years; most were white and men, lived at home, and had some college education. Mean time since SCI was 22 years; 28% had tetraplegia; mean number of prior pressure ulcers was 3; and almost one half had a previous ulcer in the same location. The strongest predictor of recurrence in a multivariate logistic regression was African American race (odds ratio = 9.3). Additional predictors included higher scores on the Charlson Co-Morbidity Index (indicating a higher burden of illness), the Salzburg PrU Risk Assessment Scales, and longer sitting time at discharge. Conclusion:Identifying individuals at highest risk for recurrence and developing effective prevention programs are essential rehabilitation goals. We recommend that the unique findings of this exploratory study be considered preliminary until replication of these results is published.

Factors predicting pressure ulcers in veterans with spinal cord injuries.

Smith BM, Guihan M, LaVela SL, Garber SL: Factors predicting pressure ulcers in veterans with spinal cord injuries. Am J Phys Med Rehabil 2008;87:750–757. Objectives:To identify patient risk factors for pressure ulcers in a sample of veterans with spinal cord injuries and disorders. Design:A survey incorporating questions from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System was mailed to individuals with spinal cord injuries and disorders in 2003. A multiple logistic regression model including 2574 respondents was used to examine the association between patient characteristics and the self-report of pressure ulcers. Results:Approximately 36% of respondents reported having pressure ulcers during the previous year. Respondent characteristics significantly associated with report of one or more pressure ulcers included diabetes (incidence rate ratio [IRR] = 1.36, P < 0.001), smoking (IRR = 1.16, P = 0.030), injury duration >30 yrs (IRR = 1.27, P = 0.000), and reporting frequent depressive symptoms (IRR = 1.30, P < 0.001). Veterans who did not have injuries related to their military service (IRR = 1.39, P < 0.001) or who received care at non-VA facilities in addition to or instead of VA facilities (IRR = 1.13, P = 0.024) were more likely than other veterans to report pressure ulcers. Conclusion:Efforts to prevent pressure ulcers should include increased attention to managing diabetes and depressive symptoms. Further research to explore the association between multiple healthcare system use and the risk of pressure ulcers should be pursued.

Using VA data for research in persons with spinal cord injuries and disorders: lessons from SCI QUERI.

The Department of Veterans Affairs (VA) provides integrated services to more than 25,000 veterans with spinal cord injuries and disorders (SCI/D). VA data offer great potential for providing insights into healthcare utilization and morbidity, and these capabilities are central to efforts to improve healthcare for veterans with SCI/D. The objective of this article is to introduce researchers to the use of VA data to examine questions related to SCI/D using examples from Spinal Cord Injury (SCI) Quality Enhancement Research Initiative studies. Sources of VA data available to investigators interested in SCI/D-related research include national-level VA administrative and clinical databases and primary data (medical record review, patient surveys). Methods used to identify veterans with SCI/D include the Allocation Resource Center cohort, the Spinal Cord Dysfunction (SCD) Registry, and the VA inpatient SCI flag; only 33% of veterans were included in all three groups (n = 12,306). While neurological level of SCI was unknown for approximately a third of veterans (from SCD Registry data alone), the percent decreased to 13% when augmented with diagnostic codes. Primary data can be used to augment other missing SCI data and to provide more detailed information about complications commonly associated with SCI/D.

Potentially modifiable risk factors among veterans with spinal cord injury hospitalized for severe pressure ulcers: a descriptive study

Abstract Context/objective Pressure ulcers (PrUs) are a serious, costly and potentially life-long complication of spinal cord injury (SCI). Co-morbid conditions increase PrU risk, adding to the health behavior challenges faced by people with SCI. Little is known about medical co-morbidities, health beliefs, risk, protective behaviors, and readiness to improve skin care behaviors in people with SCI. This study describes the potentially modifiable medical and behavioral risk factors among veterans with SCI and severe (Stage III/IV) PrUs. Design Cross-sectional observational design. Setting 6 VA SCI Centers. Participants Convenience sample from a larger intervention study of 148 veterans hospitalized for PrUs. Interventions Not applicable. Outcome measures Knowledge, PrU risk, skin protective behaviors, health beliefs, and practices, health locus of control, skin worsening. Results Most ulcers were stage IV (73%) and about half had 2+ PrUs. Participants reported a mean of 6.7 co-morbid conditions (respiratory, gastrointestinal, renal disease/urinary tract infection, autonomic dysreflexia, diabetes, bowel/bladder incontinence). Potential intervention opportunities include proactive assistance with management of multiple chronic conditions, substance abuse, nutrition, adherence to skin protective behaviors, readiness to change, and access to resources. Overall knowledge about PrUs was low, especially for how to prevent PrUs and what to do if skin breakdown occurs. Conclusion Future research should address whether comprehensive models that include patient self-management, decision support and health care system, and proactive behavior change assistance for patients help reduce PrU incidence and recurrence in persons with SCI. Trial Registration http://clinicaltrials.gov/ct2/show/NCT00105859

Assessing the feasibility of subepidermal moisture to predict erythema and stage 1 pressure ulcers in persons with spinal cord injury: A pilot study

Abstract Background Persons with spinal cord injury (SCI) are at high risk for pressure ulcers (PrUs) throughout their lifetime due to decreased mobility, lack of sensation, and other physiological changes. The high prevalence and recurrence rates, and costs associated with PrUs in veterans with SCI indicate the need for a reliable and practical method of detecting early PrUs. Objective To assess the feasibility of obtaining biophysical measures of sub-epidermal moisture (SEM) using a handheld dermal phase meter to predict PrUs. Design/methods Prospective observational design. Thirty-four veterans at two VA SCI centers (Hines, Long Beach) received daily (n = 12) or weekly (n = 22) SEM and concurrent visual skin assessment (VSA) across nine anatomic locations for up to 6 weeks. Outcome measures SEM, visual skin assessment (VSA), and stage I PrUs. Findings/results SEM was lowest for normal skin (39.3 dermal phase units (DPU), SD = 12.6) and higher for erythema/stage 1 PrUs (40.8 DPU, SD = 10.4) across all anatomic sites. Buttocks SEM were different between normal skin (40.5 DPU, SD = 10.3) and erythema/stage1 PrUs (43.8, SD = 9.5). SEM taken at heels were lower across all skin conditions (normal skin 28.2 DPU; erythema/stage 1 PrUs 34.7 DPU). SEM was taken when generalized edema present was lower than without generalized edema. Conclusions Preliminary results of using SEM to detect early PrU damage may translate from nursing home (NH) residents to persons with SCI. This study provides a foundation for a larger study to implement and assess SEM use as a method of prevention of PrUs.

Prevalence of Subacute Patients in Acute Care: Results of a Study of VA Hospitals

Subacute care is a transitional level of care for medically stable patients who no longer require daily diagnostic/invasive care but require more intensive care than is typical in a skilled care facility. A Congressionally mandated study was undertaken to determine the number of VA patients with subacute needs being cared for in acute care. InterQual, Inc. subacute care criteria were retrospectively applied to 858 medical and surgical admissions from 43 VA hospitals. Over one-third contained at least one subacute day; with an average length of stay (LOS) of 12.7 days (SD = 12.4); of which 6.8 days were subacute. Patients with these admissions had significantly longer LOSs, were older, and were more likely to die or to be discharged to a nursing home. Diagnoses with subacute days included COPD, pneumonia, joint replacement, and cellulitis. Future studies should develop clinical pathways to prospectively manage admissions with subacute needs and then evaluate their effectiveness.

Implementation of clinical practice guidelines for prevention of thromboembolism in spinal cord injury.

Abstract Background/Objectives: The purpose of this study was to determine whether publication of the “Prevention of Thromboembolism in Spinal Cord Injury” clinical practice guideline (CPG) changed patient management and whether adherence to CPG recommendations improved after a targeted implementation strategy. Methods: Data were abstracted from medical records of 1 34 and 520 patients with acute and chronic spinal cord injury (SCI), respectively, from 6 Veterans Affairs medical centers over 3 time periods: prepublication (T1 ), pre implementation (T2), and postimplementation (T3) of the CPG. Targeted interventions were developed to address provider-perceived barriers to guideline adherence, based on findings from focus groups conducted at each site. The interventions incorporated two implementation strategies: standardized documentation templates/standing orders and social marketing /outreach visits. Results: Use of the specified duration for pharmacologic prophylaxis increased from 60% to 65% to 75% of patients with acute SCI in T1, T2, and T3, respectively (P = 0.060 and 0.041 for T1 vs T2 and T2 vs T3, respectively). Rates of use for individual pharmacologic prophylaxis agents changed significantly over the course of the study, with use of low-molecular-weight heparin increasing from 7% in T1 to 42% in T3. Physical assessments for thrombosis on hospitalization days 1 and 30 improved between T2 and T3. Use of prophylaxis in chronically injured patients with new risk factors for thromboembolism increased from 16% to 31% to 34% during T1, T2, and T3 (P = 0.001 and 0.87, respectively). Conclusions: The CPG publication had only a modest effect on practice. Use of structured implementation further increased the adherence to some CPG recommendations for thromboembolism prophylaxis. Similar implementation strategies should be considered for CPG recommendations with low adherence and high potential for morbidity and mortality.

Implementing Evidence-Based Patient Self-Management Programs in the Veterans Health Administration: Perspectives on Delivery System Design Considerations

While many patient self-management (PSM) programs have been developed and evaluated for effectiveness, less effort has been devoted to translating and systematically delivering PSM in primary and specialty care. Therefore, the purpose of this paper is to review delivery system design considerations for implementing self-management programs in practice. As lessons are learned about implementing PSM programs in Veterans Health Administration (VHA), resource allocation by healthcare organization for formatting PSM programs, providing patient access, facilitating PSM, and incorporating support tools to foster PSM among its consumers can be refined and tailored. Redesigning the system to deliver and support PSM will be important as implementation researchers translate evidence based PSM practices into routine care and evaluate its impact on the health-related quality of life of veterans living with chronic disease.