Purpose
To develop a vision for the future of disaster nursing, identify barriers and facilitators to achieving the vision, and develop recommendations for nursing practice, education, policy, and ...research.
Design and Methods
A series of semistructured conference calls were conducted with 14 national subject matter experts to generate relevant concepts regarding national nursing workforce preparedness. An invitational daylong workshop hosted by the Veterans Emergency Management Evaluation Center, U.S. Department of Veterans Affairs, was held in December 2014 to expand and refine these concepts. Workshop participants included 70 nurses, emergency managers, and a broad range of public health professionals. Conference call notes and audiotapes of the workshop were transcribed and thematic analysis conducted to outline a vision for the future of nursing in disaster preparedness and response, and to articulate an agenda for nursing practice, education, policy, and research to achieve that vision.
Findings
The group developed a vision for the future of disaster nursing, and identified current barriers and opportunities to advance professional disaster nursing. A broad array of recommendations for nursing practice, education, policy, and research, as well as implementation challenges, are summarized in this article.
Conclusions
This project represents an important step toward enhancing nurses’ roles as leaders, educators, responders, policymakers, and researchers in disaster preparedness and response. Nurses and the health and human service organizations that employ them are encouraged to engage in an expansive national dialogue regarding how to best incorporate the vision and recommendations into their individual lives and the organizations for which they work.
Clinical Relevance
Nurses comprise the largest healthcare workforce, and opportunities exist to strengthen disaster readiness, enhance national surge capacity, and build community resiliency to disasters.
Purpose
Climate change, human conflict, and emerging infectious diseases are inexorable actors in our rapidly evolving healthcare landscape that are triggering an ever‐increasing number of disaster ...events. A global nursing workforce is needed that possesses the knowledge, skills, and abilities to respond to any disaster or large‐scale public health emergency in a timely and appropriate manner. The purpose of this article is to articulate a compelling mandate for the advancement of disaster nursing education within the United States with clear action steps in order to contribute to the achievement of this vision.
Design and Methods
A national panel of invited disaster nursing experts was convened through a series of monthly semistructured conference calls to work collectively towards the achievement of a national agenda for the future of disaster nursing education.
Findings
National nursing education experts have developed consensus recommendations for the advancement of disaster nursing education in the United States. This article proposes next steps and action items to achieve the desired vision of national nurse readiness.
Conclusions
Novel action steps for expanding disaster educational opportunities across the continuum of nursing are proposed in response to the current compelling need to prepare for, respond to, and mitigate the impact of disasters on human health. U.S. educational institutions and health and human service organizations that employ nurses must commit to increasing access to a variety of quality disaster‐related educational programs for nurses and nurse leaders.
Clinical Relevance
Opportunities exist to strengthen disaster readiness and enhance national health security by expanding educational programming and training for nurses.
Background
Using structured templates to guide providers in communicating key information in electronic referrals is an evidence-based practice for improving care quality. To facilitate referrals in ...Veterans Health Administration’s (VA) Cerner Millennium electronic health record, VA and Cerner have created “Care Pathways”—templated electronic forms, capturing needed information and prompting ordering of appropriate pre-referral tests.
Objective
To inform their iterative improvement, we sought to elicit experiences, perceptions, and recommendations regarding Care Pathways from frontline clinicians and staff in the first VA site to deploy Cerner Millennium.
Design
Qualitative interviews, conducted 12–20 months after Cerner Millennium deployment.
Participants
We conducted interviews with primary care providers, primary care registered nurses, and specialty providers requesting and/or receiving referrals.
Approach
We used rapid qualitative analysis. Two researchers independently summarized interview transcripts with bullet points; summaries were merged by consensus. Constant comparison was used to sort bullet points into themes. A matrix was used to view bullet points by theme and participant.
Results
Some interviewees liked aspects of the Care Pathways, expressing appreciation of their premise and logic. However, interviewees commonly expressed frustration with their poor usability across multiple attributes. Care Pathways were reported as being inefficient; lacking simplicity, naturalness, consistency, and effective use of language; imposing an unacceptable cognitive load; and not employing forgiveness and feedback for errors. Specialists reported not receiving the information needed for referral triaging.
Conclusions
Cerner Millennium’s Care Pathways, and their associated organizational policies and processes, need substantial revision across several usability attributes. Problems with design and technical limitations are compounding challenges in using standardized templates nationally, across VA sites having diverse organizational and contextual characteristics. VA is actively working to make improvements; however, significant additional investments are needed for Care Pathways to achieve their intended purpose of optimizing specialty care referrals for Veterans.
Since the onset of the COVID-19 pandemic, telehealth has been an option for Veterans receiving urgent care through Veterans Health Administration Community Care (CC).
We assessed use, arrangements, ...Veteran decision-making, and experiences with CC urgent care delivered via telehealth.
Convergent parallel mixed methods, combining multivariable regression analyses of claims data with semistructured Veteran interviews.
Veterans residing in the Western United States and Hawaii, with CC urgent care claims March 1 to September 30, 2020.
In comparison to having in-person only visits, having a telehealth-only visit was more likely for Veterans who were non-Hispanic Black, were urban-dwelling, lived further from the clinic used, had a COVID-related visit, and did not require an in-person procedure. Predictors of having both telehealth and in-person (compared with in-person only) visits were other (non-White, non-Black) non-Hispanic race/ethnicity, urban-dwelling status, living further from the clinic used, and having had a COVID-related visit. Care arrangements varied widely; telephone-only care was common. Veteran decisions about using telehealth were driven by limitations in in-person care availability and COVID-related concerns. Veterans receiving care via telehealth generally reported high satisfaction.
CC urgent care via telehealth played an important role in providing Veterans with care access early in the COVID-19 pandemic. Use of telehealth differed by Veteran characteristics; lack of in-person care availability was a driver. Future work should assess for changes in telehealth use with pandemic progression, geographic differences, and impact on care quality, care coordination, outcomes, and costs to ensure Veterans' optimal and equitable access to care.
Objective
Receipt of follow‐up care after emergency department (ED) visits for chronic ambulatory care sensitive conditions (ACSCs)—asthma, chronic obstructive pulmonary disease, heart failure, ...diabetes, and/or hypertension—is crucial. We assessed Veterans' follow‐up care knowledge, perceptions, and receipt of care after visits to Veterans Health Administration (VA) EDs for chronic ACSCs.
Methods
Using explanatory sequential mixed methods, we interviewed Veterans with follow‐up care needs after ACSC‐related ED visits, and manually reviewed ED notes, ing interviewees' documented follow‐up needs and care received.
Results
We interviewed and reviewed ED notes of 35 Veterans, 12–27 (mean 19) days after ED visits. Follow‐up care was completely received/scheduled in 20, partially received/scheduled in eight, and not received in seven Veterans. Among those who received care, it was received within specified time frames half the time. However, interviewees often did not recall these time frames or reported them to be longer than specified in the ED notes. Veterans who had not yet received or scheduled follow‐up care commonly did not recall follow‐up care instructions, believed that they did not need this care since they were not currently having symptoms, or thought that such care would be difficult to obtain due to appointment unavailability and/or difficulties communicating with follow‐up care providers. Among the 28 Veterans in whom all or some follow‐up care had been received/scheduled, for 25 cases VA staff reached out to the Veteran or the appointment was scheduled prior to or during the ED visit.
Conclusions
VA should prioritize implementing processes for EDs to efficiently communicate Veterans' needs to follow‐up care providers and systems for reaching out to Veterans and/or arranging for care prior to Veterans leaving the ED. VA should also enhance practices using multimodal approaches for educating Veterans about recommended ED follow‐up care and improve mechanisms for Veterans to communicate with follow‐up care providers.
Abstract Background Qualitative methods are a critical tool for enhancing implementation planning and tailoring, yet rapid turn-around of qualitative insights can be challenging in large ...implementation trials. The Department of Veterans Affairs-funded EMPOWER 2.0 Quality Enhancement Research Initiative (QUERI) is conducting a hybrid type 3 effectiveness-implementation trial comparing the impact of Replicating Effective Programs (REP) and Evidence-Based Quality Improvement (EBQI) as strategies for implementing three evidence-based practices (EBPs) for women Veterans. We describe the development of the Rapid Implementation Feedback (RIF) report, a pragmatic, team-based approach for the rapid synthesis of qualitative data to aid implementation planning and tailoring, as well as findings from a process evaluation of adopting the RIF report within the EMPOWER 2.0 QUERI. Methods Trained qualitative staff conducted 125 semi-structured pre-implementation interviews with frontline staff, providers, and leadership across 16 VA sites between October 2021 and October 2022. High-priority topic domains informed by the updated Consolidated Framework for Implementation Research were selected in dialogue between EMPOWER 2.0 implementation and evaluation teams, and relevant key points were summarized for each interview to produce a structured RIF report, with emergent findings about each site highlighted in weekly written and verbal communications. Process evaluation was conducted to assess EMPOWER 2.0 team experiences with the RIF report across pre-implementation data collection and synthesis and implementation planning and tailoring. Results Weekly RIF updates supported continuous EMPOWER 2.0 team communication around key findings, particularly questions and concerns raised by participating sites related to the three EBPs. Introducing the RIF report into team processes enhanced: team communication; quality and rigor of qualitative data; sensemaking around emergent challenges; understanding of site readiness; and tailoring of REP and EBQI implementation strategies. RIF report findings have facilitated rapid tailoring of implementation planning and rollout, supporting increased responsiveness to sites’ needs and concerns. Conclusions The RIF report provides a structured strategy for distillation of time-sensitive findings, continuous team communication amid a complex multi-site implementation effort, and effective tailoring of implementation rollout in real-time. Use of the RIF report may also support trust-building by enhancing responsiveness to sites during pre- and early implementation. Trial registration Enhancing Mental and Physical Health of Women Veterans (NCT05050266); https://clinicaltrials.gov/study/NCT05050266?term=EMPOWER%202.0&rank=1 Date of registration: 09/09/2021.
This article reports findings of a qualitative study describing how the US Department of Veterans Affairs cared for vulnerable veterans after Hurricane Sandy while medical center was closed for an ...extended period. This experience highlights how vulnerable patients continued to need care. Hospital preparedness planning efforts focus primarily on sheltering in place and evacuation. Research is needed to identify how hospitals provided temporary emergency services in alternative settings to inform practical guidance. Hospital planners should anticipate that their most vulnerable patients will continue to need emergency care. Viable solutions should be considered to meet immediate and long-term patient needs.
Introduction: Since 1970, natural disasters have led to both temporary and permanent closures of multiple medical centers and outpatient clinics at the US Department of Veterans Affairs (VA) ...nationwide. Access to care during such events is critical for vulnerable populations, especially homeless veterans. As such, facility closures may disproportionately affect homeless veteran patients who are both more likely to experience adverse effects from disasters and face multiple barriers to care. Methods: A cross-sectional survey was administered to a probability sample of 2000 homeless VA patients living in and receiving VA health care in the Northeast United States. The survey was completed by 383 respondents (20% adjusted response rate). This pilot study examines predictors of difficulty accessing care in the event that the VA facility that homeless VA patients routinely use is forced to close because of a natural disaster. Results: In a multivariate logistic regression, homeless VA patients who had Medicaid were less likely (OR 0.38; 95% CI: 0.18-0.78; P < .01) to report that they would have difficulty obtaining care elsewhere if their normal VA facility was closed in a future natural disaster. Conclusions: Findings suggest that Medicaid coverage has the potential to facilitate access to care for homeless veteran VA patients during disasters. Policy changes that decrease Medicaid coverage could limit access to care for homeless veterans during closures of VA medical facilities.
The largest gas leak in United States history occurred October 2015 through February 2016 near Porter Ranch (PR), California, and prompted the temporary relocation of nearby residents because of ...health concerns related to natural gas exposure.
A retrospective cohort study was conducted using US Department of Veterans Affairs (VA) administrative and clinical data. On the basis of zip codes, we created two groups: PR (1920 patients) and San Fernando Valley (SFV) (15 260 patients) and examined the proportion of outpatient visits to VA providers with respiratory-related diagnoses between October 2014 and September 2017.
We observed an increase in the proportion of visits in the PR group during the leak (7.0% vs 6.1%, P<0.005) and immediately after the leak (7.7% vs 5.3%, P<0.0001). For both groups, we observed a decrease in respiratory diagnoses one year after the leak (7.0% to 5.9%, P<0.05 PR; 6.1% to 5.7%, P<0.01 SFV).
Exposure to natural gas likely led to the observed increase in respiratory-related diagnoses during and after the PR gas leak. Early relocation following natural gas leaks may mitigate respiratory exacerbations. (Disaster Med Public Health Preparedness. 2019;13:419-423).
PDF