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March 12-18, 2017 is Patient Safety Awareness Week. Patient safety focuses on reducing harms and preventable mortality for all patients in areas such as infection control and diagnostic errors, to name a few. VA research on patient safety focuses on the reduction and prevention of inadvertent harm to Veterans receiving VA healthcare. Some of the important issues being studied by HSR&D researchers include medication safety, inpatient psychiatric safety, and using health information technology to reduce diagnostic errors and improve communication between healthcare providers.
Following are descriptions and findings from several specific research projects conducted by HSR&D and QUERI (Quality Enhancement Research Initiative) investigators on issues critical to improving patient safety for all VA patients.
Over the past two decades, a dramatic rise in the sale of prescription opioids in the United States has coincided with the rise of opioid overdose deaths and other opioid-related adverse outcomes. Further, prescribing higher total daily dosages of opioids and co-prescribing benzodiazepines have been associated with a greater likelihood of opioid overdose. In response, VA leadership developed and implemented the Opioid Safety Initiative (OSI) in 2013 to promote safer opioid-related prescribing in the VA healthcare system. Key components of the OSI include a dashboard tool that uses VA electronic health record data to generate displays of real-time opioid-related prescribing - and identifies a clinical leader at each facility to implement the tool and promote safer prescribing.
This QUERI-funded study examined changes associated with OSI implementation among all adult VA patients who filled outpatient opioid prescriptions from October 2012 through September 2014 in any of 141 VA facilities. Investigators focused on total daily opioid dosages at thresholds of >100 morphine-equivalent milligrams (mEq) and >200 mEq because these have been associated with increased risk of unintentional overdose. Findings show:
Implications: The implementation of the OSI dashboard tool was associated with a significant decrease in risky opioid prescribing across the VA healthcare system, which highlights the possibility of system-wide approaches to address high-risk opioid prescribing.
Lin L, Bohnert A, Kerns R, et al. Impact of the opioid safety initiative on opioid-related prescribing in Veterans. Pain. January 4, 2017; Epub ahead of print.
VA has been a leader in infection control with the MRSA (Methicillin-Resistant Staphylococcus Aureus) Prevention Initiative to prevent infections in both acute-care and long-term care. Current infection prevention practices in long-term care facilities (LTCFs) are adopted from those designed for acute-care settings and may not be appropriate for a LTCF population. In Community Living Centers (CLCs), VA is committed to providing Veterans with long-term, residential care that embodies the attributes of a home-like environment. The use of isolation in CLCs varies by facility from very aggressive (long-term isolation of those unable to perform personal hygiene or with active infections) to conservative (using standard precautions for all patients, primarily hand hygiene). These policies are based on low-quality data and the effect of this practice variation between CLCs is unknown; however these issues are of critical significance to the nearly 45,000 Veterans residing in a CLC. Moreover, CLC residents often require transfer to acute-care facilities for infections and have led to outbreaks in acute care.
Because Community Living Centers constitute both a home-like residence and a medical facility, understanding MRSA isolation practices in CLCs requires a multi-method approach that accounts for both national comparative effectiveness data and front-line perspectives on the barriers to adhering to infection prevention policies. Therefore, this ongoing comparative effectiveness study (2015-2019) will assess all VA Community Living Centers to assess MRSA isolation practice (as an exposure) and use unique VA databases for outcomes on MRSA acquisition and infection, as well as unintended consequences. Through these integrated projects, investigators will determine which aspects of isolation are associated with 1) MRSA prevention and 2) unintended consequences - and how future infection prevention efforts can best improve overall patient safety. [For questions or help with CLC policies, please contact Dr. Daniel Morgan at Daniel.morgan2@va.gov .]
Implications: This information will advance the science of patient safety in long-term care and inform more rational policy and education for infection prevention in VA Community Living Centers.
A person with dementia of the Alzheimer's type will live an average of four to eight years, and as long as 20 years, after the onset of symptoms. During this illness trajectory, the overwhelming majority of the person's care is provided by family and friends, who serve as a safety net for the person with dementia. A Home Safety Toolkit has been shown to improve safety for Veterans with dementia and decrease caregiver strain. The purpose of this ongoing QUERI-funded study (2014-2017) was to examine the processes necessary to make a Home Safety Toolkit (HST) for Veterans with dementia accessible to these patients and their caregivers - and to gather additional information about the effectiveness of the HST when implemented in VA primary care clinics. Investigators interviewed key staff informants (i.e., physicians, nurses, occupational therapists, and Prosthetics and Sensory Aids managers) who had experience in assessing, prescribing, and/or providing home safety items for Veterans in the past six months. In addition, patients' and caregivers' perceptions of the facilitators of and barriers to successful acquisition and use of home safety items were explored. Investigators also evaluated the implementation strategies that are successful to provide the HST to Veterans with dementia and their primary caregivers.
The overall primary outcome for this study was to be the number of Veterans with dementia and their caregivers who received a Home Safety Toolkit. However, inconsistent policy regarding items deemed ‘not medical equipment' prevented national institution of an HST order set within CPRS (computerized patient record system), and thus dissemination efforts will focus instead on distribution of the companion home safety workbook.
Implications: The evidence-based Home Safety Toolkit for Dementia was shown to reduce family caregiver strain, reduce Veterans' risky behaviors and accidents, and increase family caregiver home safety modifications and self-efficacy. This study will help make the HST information accessible to Veterans across VA through primary care providers.
There is wide agreement that senior management support is critical to sustained improvement in quality of care and patient safety - and to the development of organizations that have the capability and flexibility to continuously improve. Less clear is how support can be effectively translated to practical actions by managers, especially senior medical center leaders. This ongoing QUERI-funded study (2014-2017) is testing a practical program for engaging senior managers with frontline staff in order to identify and address quality and patient safety improvement opportunities. Leveraging Frontline Expertise (LFLE) is a structured program that engages senior managers through four iterative components in selected work areas: 1) information gathering, 2) action planning, 3) improvement actions, and 4) feedback to staff.
Specific study objectives include:
Study sites (12 VA medical centers) were recruited from a pool of medical centers that expressed commitment to implementing the LFLE program. Primary data collection from LFLE participants includes: semi-structured interviews, feedback and tracking tool questionnaires about LFLE implementation, and pre- and post-implementation organizational surveys. Secondary data sources include study team implementation records and VA administrative databases.
Implications: The study will impact Veterans' healthcare by improving the ability of VA medical centers to improve continuously and to incorporate new practices into hospital services that provide high value in safety, quality, and efficiency of care.
Aging Veterans are the largest growing cohort in the VA patient population, and pain-related disorders are the most prevalent of health-related conditions. Observational studies using administrative data have raised concerns about the safety of opioid versus non-steroidal anti-inflammatory drug (NSAID) analgesics in older adults, medications commonly prescribed to Veterans. However, research gaps in optimal older adult pain treatment remain and more evidence-based research is needed before conclusive recommendations and guidelines can be endorsed. This ongoing study (2014-2018) is evaluating the safety and effectiveness of three commonly used analgesic medication drug classes, including opioids, NSAIDs, and coxibs (non-steroidal anti-inflammatory drug) for patients with chronic pain. Specific aims are to determine the:
The first phase of this study includes a prospective survey of older Veterans with arthritis recruited from primary care clinics at four different VA medical centers with geographic and prescribing-pattern diversity, while the second phase will utilize a national cohort to compare the safety of NSAIDs, selective coxibs, and opioids. Investigators will use VA administrative data - linked to Medicare and Medicaid claims data - in order to allow for a robust evaluation of patient safety outcomes.
While data collection remains ongoing, preliminary findings indicate only fair agreement between self-reported analgesics versus medical record analgesic prescriptions, which varied based on drug class, including opioids, NSAIDs , and others (i.e., coxibs, acetaminophen, and topical analgesics).
Implications: Discordance exists between health record-documented and self-reported analgesic use among older Veterans. Studies utilizing administrative health record data for pharmacoepidemiological analgesic safety studies should be interpreted with consideration of the degree of actual medication exposure.
